450 625-2030
English
Français
(
French
)
Our services
General Care
Dental Exam and Cleaning
Family Dentistry
Dental Emergencies
Mouthguards and Occlusal Splints
Treatments
Dental Restorations
TMJ
Periodontics
Denturology
Cosmetic Dentistry
Cosmetic Dentistry
Injection of neuromodulators (Botox®)
CEREC Technology
Crowns and Bridges
Invisalign® Invisible Orthodontics
Teeth Whitening
Surgery
Endodontics
Implantology
Wisdom Tooth Extraction
The clinic
Our team
Visit our clinic
Patient information
Postoperative Instructions
Medical questionnaire
CDCP
Minor Consent Form
Adult Consent Form
Contact us
Appointment
450-625-2030
Menu
<
Retour
✕
Our services
Retour
Our services
General Care
Dental Exam and Cleaning
Family Dentistry
Dental Emergencies
Mouthguards and Occlusal Splints
Treatments
Dental Restorations
TMJ
Periodontics
Denturology
Cosmetic Dentistry
Cosmetic Dentistry
Injection of neuromodulators (Botox®)
CEREC Technology
Crowns and Bridges
Invisalign® Invisible Orthodontics
Teeth Whitening
Surgery
Endodontics
Implantology
Wisdom Tooth Extraction
The clinic
Retour
The clinic
Our team
Visit our clinic
Patient information
Retour
Patient information
Postoperative Instructions
Medical questionnaire
CDCP
Minor Consent Form
Adult Consent Form
Contact us
Appointment
450 625-2030
English
Français
(
French
)
Minor Consent Form
Consent Form for the Collection and Use of a Minor's Personal Information
I, the undersigned,
, hereby give my consent to the collection, use, and disclosure of the personal information of the minor,
, of whom I am the legal guardian, by ESPACE DENTAIRE MD for the purpose of providing them with dental services. I acknowledge having received information on how their personal information will be collected, used, shared, stored, and protected. I acknowledge having received information on their rights regarding their personal information. The above information can be found in ESPACE DENTAIRE MD's Privacy Policy. I understand that consent is valid as long as the minor is a patient of ESPACE DENTAIRE MD and that I can withdraw consent to the collection and use of
_________________
's personal information at any time, according to the procedure described in ESPACE DENTAIRE MD's privacy policy. However, this may prevent ESPACE DENTAIRE MD from providing them with dental services. I have read and understood the above information and voluntarily consent to the collection and use of personal information as described.
Signature
Delete signature
Date:
Send
2026-07-31 15:52:11
Reject
→
Cookies
This website uses cookies to ensure proper functionality and a better browsing experience. By using this site, you consent to our use of cookies as described in the
privacy policy
.
