​

CONSENT FORM FOR PHARMACY FILE TRANSFER

​

Patient name: _______________________

[Residence name: _______________________]

​

Address: _______________________

​

From: Current pharmacy: _______________________

​

To: Pharmacie Abd-el-monem Osman Inc. 245 Hymus, Montréal, H9R 1G6.

​

I agree to transfer my prescriptions and patient file to the pharmacy named above. This form will be sent to my current pharmacist as proof of my consent. This is my own decision, and I remain free to change pharmacies at any time. If I do change pharmacies, this authorization will no longer be valid.

​

Date: _______________________

Signature: _______________________ (patient or representative)

Note: If signed by a representative, written proof of legal authority may be required.