1150 Boulevard de la Grande-Allée, suite 102, Boisbriand, QC J7G 2T4
I, SelectMissMs.Mr. , hereby consent to the collection, use and disclosure of the personal information of the minor, of whom I am the legal guardian, by Centre Dentaire Paradis for the purpose of providing dental services.
I acknowledge that I have received information on how my personal information will be collected, used, shared, stored and protected.
I acknowledge that I have received information about my rights with respect to my personal information.
The foregoing information is contained in the Centre Dentaire Paradis Privacy Policy.
I understand that consent is valid for as long as the minor is a patient of Centre Dentaire Paradis and that I may withdraw consent to the collection and use of _________________'s personal information at any time in accordance with the procedure described in Centre Dentaire Paradis's Privacy Policy. However, this may prevent Centre Dentaire Paradis from providing dental services.
I have read and understood the above information and voluntarily consent to the collection and use of personal information as described.
Signature
Printed name: ____ _________________
Printed name of minor: _________________
Date: