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Consent to the collection and use of personal information

I consent to the collection, use and disclosure of my personal information by Centre dentaire familial du Richelieu for the purpose of providing me with dental services.

I acknowledge that I have received information about how my personal information will be collected, used, shared, stored and protected, and about my rights. This information is set out in the privacy policy.

I understand that this consent remains valid for as long as I am a patient of the clinic, and that I may withdraw it at any time by following the procedure described in the privacy policy, although doing so may prevent the clinic from providing me with dental services.

I have read and understood the information above and I freely consent to the collection and use of personal information as described.

Consent to communicate with a health professional (optional)

Family doctor, specialist, pharmacist or other.

Name

Profession

Facility or phone

I consent to the dentist and staff obtaining from, or sharing with, this professional any information relevant to my file.

I have completed this medical and dental questionnaire to the best of my knowledge.

Signature: type your full name

Your typed name serves as your signature. The submission date is added automatically.

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