Confidentiality of Information

Privacy Code

Privacy of personal information is important to the Canadian Memorial Chiropractic College. We are committed to the collection, use and disclosure of this information in a responsible way. We will also try to be as open and transparent as to how we handle personal information.

Personal Information
Personal information is information about an identifiable individual. Generally, the information we collect is limited to your name, home contact information, gender and age. As part of your patient file we retain your health history; health measurements and examination results; health conditions, assessment results and diagnoses; the health services provided to you or received by you; your prognosis and other opinions formed; compliance with treatment; and the reasons for your discharge and discharge recommendations. We also maintain records for payment and billing purposes. Only necessary information is collected about you. We only share your information with your consent; the use, retention and destruction of your personal information complies with existing legislation and privacy protection protocols. Privacy protocols comply with privacy legislation, standards of our regulatory body, the College of Chiropractors of Ontario and the law.

Staff Members
Staff members who come into contact with your personal information are aware of the sensitive nature of the information you have disclosed to us. They are all trained in the appropriate uses and protection of your information. These individuals include the clinic records personnel that control access to your patient file, the clinicians and interns that provide you with chiropractic services, the clinic administration and, when necessary, authorized individuals who may inspect our records as part of the regulatory activities in the public interest.

Disclosure of Personal Information
Our clinics understand the importance of protecting your personal information. To help you understand how we are doing that, we outline below how our clinics use and disclose this information:

  • To deliver safe and effective patient care
  • To enable us to contact you
  • To communicate with other health care providers
  • For teaching and demonstrating on an anonymous basis
  • To complete and submit claims on your behalf to third party payors
  • To comply with legal and regulatory requirements under the Chiropractic Act and the Regulated Health Professions Act
  • To process payments and collect unpaid accounts
  • For research purposes

By signing the consent section of this form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance.


Treatment follow up:

Home phone: (___) ____-______  Leave Message: Yes No

Business phone: (___) ____-______ Leave Message: Yes No

Cell phone: (___) ____-______  Leave Message: Yes No

Email: ________________________ Do not call: 

Do you want to be included in future emails   Yes  No
regarding events and information?

Patient Consent

I have reviewed the above information that explains how our clinics will use my personal information. I know that the Canadian Memorial Chiropractic College has a Privacy Code and I may ask to see it at any time.

I agree that the Canadian Memorial Chiropractic College Teaching Clinics can collect, use and disclosure my personal information as set out above in the College’s privacy code.


(Print Name)


(Signature of Witness)