Consent to transfer dental records

Your first name Your last name Your Phone number Reason for transfer
Recipient My email addressDental office / third party below: Dental office name Dental office email Please choose one of the following options; Inactivate my file: I want to inactivate my file at ABAN Yaletown dental.Keep my file active: I want to keep my file active at ABAN Yaletown Dental. You may still receive correspondences like appointment notices from our office.

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):

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