Patient Referral Form
Patient Referral Form
Dr. Christa Favot, DDS, M.SC, FRCD(C)
2037 Long Lake Road, Sudbury, ON P3E 6J9
Office: 705-222-3223 Fax: 705-621-0507
Terms of Service and Privacy Policy
1. This online referral system allows practices to refer patients to our office. 2. All information submitted in this online referral form will be treated by the clinic as part of your confidential patient record. 3. Total privacy and confidentiality is ensured for both the patient and doctor. 4. Patient information will be encrypted by the secure server software (SSL) before it is uploaded to the doctor's database. 5. The personal information submitted is stored at a secure server in encrypted format. All of the patient information collected is protected against unauthorized access. 6. Information collected will not be shared with any third parties. 7. Only the patient's doctor office will have access to their personal data via a secured, proprietary method. 8. Referral information is purged periodically from the server and does not remain in the database indefinitely. 9. The protocol used in this site is compliant with the PIPEDA Policies and Procedures for accepting and viewing patient data records. 10.The user of this site expressly understands and agrees the clinic and the service/hosting provider ("OptiMicro" and its subsidiaries, affiliates, officers, partners and agents) shall not be liable to you for any direct, indirect, incidental special, consequential or exemplary damages, including, but not limited to, damages from loss of profits, goodwill, use, data or other intangible losses resulting from (a) the cost of procurement of substitute services (b) the use or the inability to use the Service (c) unauthorized access to or alteration of your transmission or data (d) Statements or conduct of any third party on the Service or (e) any other matter relating to the Service.
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Yes, I have read and agree to the above Terms of Service and Privacy Policy.