{"id":26959,"date":"2023-08-14T14:27:58","date_gmt":"2023-08-14T14:27:58","guid":{"rendered":"https:\/\/sylvainchamberland.com\/?page_id=26959"},"modified":"2023-10-09T14:16:01","modified_gmt":"2023-10-09T14:16:01","slug":"consent-form","status":"publish","type":"page","link":"https:\/\/www.sylvainchamberland.com\/en\/consent-form\/","title":{"rendered":"Consent form"},"content":{"rendered":"\n<section  class=\"o-block\">\n    <div class=\"c-text o-container\">\n        <div class=\"c-text_inner\">\n            \n                            <div class=\"c-text_content w-100\">\n                    <style>\n        .div_name_sign {\n            display: flex;\n        }\n\n       .input_text_style {\n            display: inline-block;\n            width: 335px;\n            margin-bottom: 15px;\n            margin-left: 5px;\n            appearance: auto;\n            border: 1px solid var(--primary-700);\n            border-radius: .25rem;\n            height: 2.2rem;\n            padding: 0 0.6rem;\n        }\n\n        .input_text_style::placeholder {\n            font-style: italic;\n        }\n\n        .input_tel_style {\n            display: inline-flex;\n            width: 115px;\n            margin-bottom: 18px;\n            margin-left: 5px;\n        }\n        .input_text_style:nth-child(1) {\n            margin-top: 5px;\n        }\n        .input_text_style:nth-child(2) {\n            margin-bottom: 0;\n        }\n\n        .input_select {\n            width: 126px;\n            font-style: italic;\n            border: 1px solid var(--primary-700);\n            border-radius: .25rem;\n            height: 2.2rem;\n            padding: 0 0.28rem;\n        }\n\n        .consentpopnotification,\n        .page-loader.active {\n            position: fixed;\n            top: 0%;\n            height: 100%;\n            padding: 2em 0 2em 0;\n            font-size: 2em;\n            left: 0;\n            right: 0;\n            background: rgba(255, 255, 255, 1);\n            z-index: 99999999;\n            text-align: center;\n            display: block;\n            animation: fadeout 4s;\n            -moz-animation: fadeout 4s;\n            -webkit-animation: fadeout 4s;\n            -o-animation: fadeout 4s;\n            animation-delay: 4s;\n            -moz-animation-delay: 4s;\n            -webkit-animation-delay: 4s;\n            -o-animation-delay: 4s;\n            animation-fill-mode: forwards;\n            -webkit-animation-fill-mode: forwards;\n            -moz-animation-fill-mode: forwards;\n        }\n\n        .consentpopnotification .alert-box {\n            position: absolute;\n            top:50%;\n            margin-top: -200px;\n            width: 100%;\n            text-align: center;\n            left: 0;\n            padding-left:1em;\n            padding-right: 1em;\n            box-sizing: border-box;\n            -moz-box-sizing: border-box;\n        }\n\n        .page-loader {\n            display: flex !important;\n            align-items: center;\n            justify-content: center;\n            background: #ffffff80 !important;\n        }\n\n        .page-loader .loader {\n            border: 10px solid #f3f3f3;\n            border-radius: 50%;\n            border-top: 10px solid #3498db;\n            width: 100px;\n            height: 100px;\n            -webkit-animation: spin 2s linear infinite; \/* Safari *\/\n            animation: spin 2s linear infinite;\n        }\n\n        .h4-style {\n            font-size: 1.4375rem;\n            line-height: 1.2173913043;\n            color: #1f364c;\n        }\n\n        .send_consent {\n            margin-top: 1.5rem;\n        }\n\n        \/* Safari *\/\n        @-webkit-keyframes spin {\n            0% { -webkit-transform: rotate(0deg); }\n            100% { -webkit-transform: rotate(360deg); }\n        }\n\n        @keyframes spin {\n            0% { transform: rotate(0deg); }\n            100% { transform: rotate(360deg); }\n        }\n\n\n        @media screen and (max-width: 700px) {\n            .input_text_style {\n                width: 100%;\n            }\n        }\n    <\/style>\n\n    \n    <div class=\"page-loader\"><\/div>\n\n    <div class=\"consent-form-shortcode canvas_div_pdf\">\n        <form class=\"consent-form\" id=\"send_consent_by_email\" method=\"get\" action=\"https:\/\/www.sylvainchamberland.com\/wp-admin\/admin-ajax.php\">\n            \n            <input type=\"hidden\" id=\"language_code\" name=\"language_code\" value=\"en\">\n            <input type=\"hidden\" name=\"consent_goto\"  id=\"consent_goto\" value=\"https:\/\/www.sylvainchamberland.com\/en\/visit-the-clinic\/\"\/>\n            <input type=\"hidden\" name=\"date_1\" id=\"date_1\" value=\"1 June 2023\"\/>\n            <input type=\"hidden\" name=\"date_2\" id=\"date_2\" value=\"15 august 2023\"\/>\n\n            <h2>Privacy Policy for Dr Sylvain Chamberland Orthodontiste Inc.<\/h2>\n            <p class=\"h4-style\">Date of entry into force: 1 June 2023<\/p>\n            <hr>\n            <p>At the <b>Dr. Sylvain Chamberland, Orthodontist<\/b> office we are committed to protecting the privacy and security of our patients&#8217; personal information. This privacy policy explains how we collect, share, use and protect your personal information in accordance with applicable laws and regulations.<\/p>\n\n            <h3>Information we collect<\/h3>\n            <p>We collect personal information from our patients in order to provide them with dental services. This information may include, but is not limited to :<\/p>\n            <ul>\n                <li>Contact details such as your name, postal address, e-mail address and telephone number;<\/li>\n                <li>Demographic information such as your age and gender;<\/li>\n                <li>Health information such as your medical history, current medication and allergies;<\/li>\n                <li>Insurance details, such as your policy number and insurance company, and;<\/li>\n                <li>Biometric information such as X-rays and dental imaging.<\/li>\n            <\/ul>\n\n            <h3>How we use your information<\/h3>\n            <p>We use your personal information to provide you with dental care: <\/p>\n            <ul>\n                <li>Making it easier to book appointments;<\/li>\n                <li>Carrying out dental examinations and treatments;<\/li>\n                <li>Maintaining and updating my dental records;<\/li>\n                <li>Managing patient accounts;<\/li>\n                <li>Contact you with reminders and follow-up information and;<\/li>\n                <li>Process insurance payments and claims.<\/li>\n            <\/ul>\n            <p>We may also use your information to improve our dental services and to comply with legal and regulatory requirements.<\/p>\n            <p>We only collect personal information that is necessary for the purposes identified in this policy. Personal information is not used or disclosed for purposes other than those for which it was collected, except with the consent of the individual or as required by law. Personal information is retained only as long as necessary for the fulfillment of those purposes.<\/p>\n\n            <h3>Our collection methods<\/h3>\n            <p>Personal information will be collected through a combination of online and paper forms, face-to-face interviews and communication with <b>Dr. Sylvain Chamberland<\/b> staff.<\/p>\n\n            <h3>Sharing information<\/h3>\n            <p>We do not share your personal information with third parties except as necessary for the provision of dental services, such as with dental laboratories for the creation of dental appliances, or with insurance companies for the processing of claims.<\/p>\n            <p><b>Dr. Sylvain Chamberland<\/b> will not give, sell or rent my personal information to third parties. We will only share information with your consent or where required by law.<\/p>\n\n            <h3>Locating your information<\/h3>\n            <p>Personal information is generally stored or processed in facilities located in Quebec. Some of this data may be processed by third parties outside Quebec. If this is the case, <b>Dr. Sylvain Chamberland<\/b> will take reasonable steps to ensure the protection of your data with the third parties in question.<\/p>\n\n            <h3>Information security<\/h3>\n            <p>We take reasonable steps to protect your personal information from unauthorised access, use or disclosure. Despite this, no security mechanism can guarantee perfect protection and there will always be some residual risk.<\/p>\n            <p>Our office uses secure filing systems, effective identity and access management and physical safeguards to protect your information, all in compliance with the laws and regulations in force.<\/p>\n\n            <h3>Your rights<\/h3>\n            <p>You have the right to access, modify or delete your personal information. You may withdraw your consent to the collection and use of your personal information at any time. However, this could prevent <b>Dr. Sylvain Chamberland<\/b>, for example, from providing you with adequate dental services.<\/p>\n            <p>You have all the rights in accordance with legal and regulatory requirements.<\/p>\n            <p>If you wish to exercise these rights, please contact the <b>Dr. Sylvain Chamberland<\/b> office at <a class=\"c-link u-whitespace-nowrap hover-secondary-700\" href=\"tel:4188471115\">418 847-1115<\/a>.<\/p>\n\n            <h3>Changes to our privacy policy<\/h3>\n            <p>We reserve the right to amend this privacy policy at any time to maintain compliance and to reflect any changes to our personal information collection process.<\/p>\n            <p>If we make significant changes to the policy, we will inform you by publishing a notice or by posting a new version of the policy on our website.<\/p>\n\n            <h3>Contact us<\/h3>\n            <p>If you have any questions about our privacy policy or the processing of your personal information, please contact us at <a class=\"c-link u-whitespace-nowrap hover-secondary-700\" href=\"tel:4188471115\">418 847-1115<\/a>.<\/p>\n\n            <p><strong>Date of entry into force: <\/strong>1 June 2023<\/p>\n            <p><strong>Date of last update: <\/strong>15 august 2023<\/p>\n\n            <!-- Nouvelle Page -->\n\n            <h2>Consent form for the collection and use of personal information<\/h2>\n            <p>I, the undersigned, <select class=\"input_text_style input_select\" name=\"name_sign_1_gender\" id=\"name_sign_1_gender\"><option value=\"\">Select<\/option><option value=\"Miss\">Miss<\/option><option value=\"Mrs.\">Mrs.<\/option><option value=\"Mr\">Mr<\/option><\/select> <input type=\"text\" class=\"input_text_style\" name=\"name_sign_1\" id=\"name_sign_1\" placeholder=\"First and last name\" \/><\/p>\n            <p>for <input type=\"text\" class=\"input_text_style\" name=\"name_sign_2\" id=\"name_sign_2\" placeholder=\"(Patient's first and last name)\" \/> hereby consents to the collection, use and disclosure of my personal information by \n            <b>Dr. Sylvain Chamberland, Orthodontist<\/b>            to provide me with dental services.<\/p>\n                        \n            <p>I acknowledge that I have received information on how my personal information will be collected, used, shared, stored and protected.<\/p>\n            <p>I acknowledge that I have received information about my rights in relation to my personal information. The above information can be found in the <b>Dr. Sylvain Chamberland, Orthodontist<\/b> privacy policy.<\/p>\n            <p>I understand that consent is valid as long as I am a <b>Dr. Sylvain Chamberland, Orthodontist<\/b> patient , and that I may withdraw my consent to the collection and use of my personal information at any time in accordance with the procedure described in the <b>Dr. Sylvain Chamberland, Orthodontist<\/b> privacy policy. However, this could prevent <b>Dr. Sylvain Chamberland<\/b> from providing me with dental services.<\/p>\n            <p>I have read and understood the above information and voluntarily consent to the collection and use of my personal information as described.<\/p>\n\n            <div class=\"signatureInner\">\n                <p><strong>Signature<\/strong><\/p>\n                <div class=\"sigPadConsentement\" id=\"sigPadConsentement_1\">\n                    <div class=\"sig sigWrapper\">\n                        <div class=\"typed\"><\/div>\n                        <canvas class=\"pad\" width=\"250\" height=\"100\"><\/canvas>\n                        <input type=\"hidden\" name=\"signature_consentement\" id=\"signature_consentement\" value=\"\" class=\"output\">\n                    <\/div>\n                    <div class=\"error-signature-consentement\"><\/div>\n                    <div class=\"clearButton\" style=\"margin-top: 10px;\">\n                        <a href=\"#clear\">Delete signature<\/a>\n                    <\/div>\n                <\/div>\n            <\/div>\n            <br>\n\n            <p><strong><span id=\"span_name_sign_1_gender_1\"><\/span> <span id=\"span_name_sign_1_1\">First and last name<\/span><\/strong><\/p>\n            <p><strong>for: <span id=\"span_name_sign_2_1\">(Patient&#8217;s first and last name)<\/span><\/strong><\/p>\n            <p><strong>Date:  <\/strong><input class=\"input_text_style datepicker consentdate\" id=\"date_3\" name=\"date_3\" inputmode=\"none\" type=\"text\" placeholder=\"DD MM YYYY\"><\/p>\n            <br><br>\n            <p><b>Patient file subject: <\/b><span id=\"span_name_sign_2_3\">(Patient&#8217;s first and last name)<\/span><\/p>\n            <p>I, <span id=\"span_name_sign_1_3\">First and last name<\/span><\/p>\n            <ul>\n                <li>I consent to <b>Dr. Chamberland<\/b> keeping in its files all relevant information relating to the treatment provided as well as the personal information necessary for the execution of the financial agreement;<\/li>\n                <li>I consent to <b>Dr. Chamberland<\/b> collecting from any person and holding any information deemed necessary for the collection of the sums provided for in the financial agreement and that, for this purpose, it may transmit the said information to whomever it deems appropriate;<\/li>\n                <li>I agree that any person may provide <b>Dr. Chamberland<\/b> with such information;<\/li>\n                <li>I agree that data relating to diagnosis and treatment (photos, X-rays) may be used for teaching, examinations, research, conferences and scientific publications;<\/li>\n                <li>I also agree that the <b>Dr. Chamberland<\/b> may keep my medical file and the information it contains;<\/li>\n                <li>I consent to the storage of my biometric data (photos, X-rays, models).<\/li>\n            <\/ul>\n\n            <div class=\"signatureInner\">\n                <p><strong>Signature<\/strong><\/p>\n                <div class=\"sigPadConsentement\" id=\"sigPadConsentement_2\">\n                    <div class=\"sig sigWrapper\">\n                        <div class=\"typed\"><\/div>\n                        <canvas class=\"pad\" width=\"250\" height=\"100\"><\/canvas>\n                        <input type=\"hidden\" name=\"signature_consentement_2\" id=\"signature_consentement_2\" value=\"\" class=\"output\">\n                    <\/div>\n                    <div class=\"error-signature-consentement\"><\/div>\n                    <div class=\"clearButton\" style=\"margin-top: 10px;\">\n                        <a href=\"#clear\">Delete signature<\/a>\n                    <\/div>\n                <\/div>\n            <\/div>\n            <br>\n\n            <p><strong><span id=\"span_name_sign_1_4\">First and last name<\/span><\/strong><\/p>\n            <p><strong><span id=\"span_name_sign_2_2\">(Patient&#8217;s first and last name)<\/span><\/strong><\/p>\n            <p><strong>Date: <\/strong><span id=\"span_date_3\">_________________<\/span><\/p>\n\n            <button class=\"button c-btn send_consent\" type=\"submit\">Send<\/button>\t\t\t\n       \n        <\/form>\n    <\/div>\n\n    <script type=\"text\/javascript\">\n\n        $(document).ready(function(){\n            var sigPadConsentement_1 = $(document).find('#sigPadConsentement_1').signaturePad({drawOnly:true,lineWidth: 0, validateFields:true, errorMessageDraw:$('.error-signature-consentement').text()});\n            var sigPadConsentement_2 = $(document).find('#sigPadConsentement_2').signaturePad({drawOnly:true,lineWidth: 0, validateFields:true, errorMessageDraw:$('.error-signature-consentement').text()});\n        \n            $('#name_sign_1').on('keyup', function(){\n                var text_value = '';\n\n                if ($(this).val() == '') {\n                    text_value = \"First and last name\";\n                } else {\n        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($(this).val() == '') {\n                    text_value = \"_________________\";\n                } else {\n                    text_value = $(this).val();                    \n                }\n\n                $('#span_date_3').text(text_value);\n            }); \n\n            $('#name_sign_1_gender').on('change', function(){\n                var text_value = '';\n\n                if ($(this).val() == '') {\n                    text_value = \"____\";\n                } else {\n                    text_value = $(this).val();                    \n                }\n\n                $('#span_name_sign_1_gender_1').text(text_value);\n                $('#span_name_sign_1_gender_2').text(text_value);\n            });\n\n            setTimeout(function() { \n                $('.consentpopnotification').remove();\n            }, 3000);\n\n            $('#send_consent_by_email').submit(function(e){\n\t\t\t\te.preventDefault();\n                \n                if 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