Transfer Policy

PATIENT FILE TRANSFER CONSENT FORM

Patient name:

Residence name:

Address:

Pharmacy name:

Sonia Boutin Pharmacy Inc.

Address:

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.

Date :

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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