The provision of quality health care requires a doctor-patient relationship of trust and confidentiality. Consistent with our commitment to quality care this practice has developed a policy to protect patient privacy in compliance with private legislation. It is necessary for us to collect personal information from patients and sometimes others associated with their health care in order to attend to their needs and for administrative purposes. In the interests of the highest quality and continuity of the patient’s health care this may also include sharing information with other health care providers who comprise a patient’s medical team from time to time. On the day of my surgery photos or videos of my procedure may be taken for administrative or teaching purposes. I understand at no time will my identity be photographed or filmed. I understand that Dr Chabert will protect my privacy in compliance with private legislation. This practice will also send a letter to all relevant health care providers detailing the treatment provided. I have read the above information and give my consent.