hereby consent to the collection, use and disclosure of my personal information by ESPACE DENTAIRE MD 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.

I acknowledge that I have received information about my rights with respect to my personal information.

The foregoing information is contained in the ESPACE DENTAIRE MD Privacy Policy.

I understand that consent is valid for as long as I am a patient of ESPACE DENTAIRE MD and that I may withdraw my consent to the collection and use of my personal information at any time in accordance with the procedure described in the ESPACE DENTAIRE MD Privacy Policy. However, this may prevent ESPACE DENTAIRE MD from providing me with dental services.

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