Privacy Policy
Note: This Privacy Policy relates to your visit with Arik Pasternak, N.D. and is separate from the Privacy Policy of the Polyclinic Family and Specialty Medicine Facility, which complies with the Personal Health Information Protection Act (Ontario) (PHIPA) and the College of Physician and Surgeons of Ontario (CPSO) Guidelines. 
Privacy of your personal information and protection of your personal information is something we take very seriously.  Only necessary information is collected about you.   We are committed to collecting, using and disclosing your personal information responsibly.  Only with your written consent do we share information with others outside of the clinic.
Storage, retention and destruction of your personal information complies with existing legislation and privacy protection protocols.  Our privacy policy conforms to legislation and standards of the Board of Directors of Drugless Therapy-Naturopathy.   Personal information is collected in order to:
·	Assess your health;
·	Provide health care;
·	Advise you of treatment options;
·	Establish and maintain contact with you regarding appointments, invoices and follow-up care;
·	Send your pertinent information and mailings;
·	Facilitate your insurance claims;
·	Comply with the legal and regulatory requirements of the Drugless Practitioners Act.
By signing below, you have agreed that you have given your informed consent to the collections, use, and/or disclosure of your personal information for the purposes outlined above.
Signature:________________________________     Date:___________________________________
Witness:__________________________________  Date:____________________________________
Print parent/guardian’s name:__________________________________________________________
(if under 18 years old)

Signature of Parent/guardian:_____________________________  Date:_________________________