Consent to transfer dental records

    Recipient Please choose one of the following options;

    I hereby consent ABAN Yaletown Dental to release / transfer all my dental records. I understand that electronic transfer of dental records including X-rays in the form of electronic transfer such as email can put my personal health information at risk which may cause breach of privacy. I hereby understand the risk and consent to transfer of dental records using email.

    Signature (Please sign below using touch screen devices or your mouse):