hereby 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 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 ESPACE DENTAIRE MD Privacy Policy.

I understand that consent is valid for as long as the minor is a patient of ESPACE DENTAIRE MD and that I may withdraw consent to the collection and use of

personal information at any time in accordance with the procedure described in ESPACE DENTAIRE MD’s Privacy Policy. However, this may prevent ESPACE DENTAIRE MD 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.