I have filled out this medical-dental questionnaire to the
best of my knowledge.
I hereby consent and state my authorization to have my
dentist and other staff at Centre Dentaire Familial communicate with me by email or
standard SMS messaging and/or iMessage
regarding various aspects of my dental care, which may include, but shall not be
limited to, follow-ups, prescriptions, appointments, and billing. I understand that
email and
standard SMS messaging and/or iMessage are not confidential methods of communication
and may be insecure. I further understand that,
because of this, there is a risk that email and standard SMS messaging and/or
iMessage regarding my dental care might be intercepted and read by a third party.
Parent/guardian (if under 14 yrs. old)
Legal/authorized representative