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PATIENT FILE TRANSFER CONSENT FORM
Pharmacie Sonia Boutin inc.
9320 Boulevard Saint-Laurent, suite 711, Montreal, QC H2N 1N7
I have read the pharmaceutical services offered by the above-mentioned pharmacy and I agree to transfer my prescriptions and my patient file to them. I understand that this form will be sent to my current pharmacist so that they are made aware of my consent. This decision was not imposed on me and I remain free to change pharmacies at any time if I am no longer satisfied. Should this happen, this authorization will no longer be valid.
Signature of patient:
(or their mandatary)
NB If this form is signed by a mandatary, written proof may be required in order to ensure that the signatory is legally authorized to sign.
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