Consent to Transfer Records

To serve you as best we can, please fill out your information below. All information will be strictly confidential.

Blue Quill Dental Centre
294 Saddleback Road, Edmonton, AB T6J 4R7
ph: 780.436.6971 fax: 587-906-8999
www.bluequilldental.com

Consent for disclosure of individually identifying health information (authorized by HIA s34)

Patient information

Name(Required)

First Last

Date of birth(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Authorization for disclosure

I authorize my individually identifying health information to be disclosed by Blue Quill Dental Centre, in accordance with section 34 of the Health Information Act, to the person or organization named below, for the purpose(s) stated.

Disclose my information to

Name of the person or organization receiving the information.

Purpose(s) of the disclosure

Acknowledgement(Required)

I acknowledge that I have been made aware of why I have been asked to consent to the disclosure of the above information and am aware of the risks and benefits associated with consenting, or refusing to consent, to the disclosure of my individually identifying health information. I understand that I may revoke my consent at any time, by providing a signed, written statement to that effect.

Signing

Are you signing on behalf of the patient?(Required)

No

Yes

Print name of authorized representative(Required)

Print source of representative's authority(Required)

For example: parent, legal guardian, power of attorney.

Witness

If a witness is required, this section is completed by hand on the printed copy of this form.

Print name of witness: ______________________________________
Signature of witness: ______________________________________
Date: ______________________________________

Please sign below. Your signature applies to this form as a whole: the consent to disclosure described above, the acknowledgement you have confirmed, and, where someone is signing on the patient's behalf, the authority stated above.