I the undersigned, hereby declare that I have read, understood, and answered the above medical-dental questionnaire to the best of my knowledge. I also hereby promise to inform you of any change to my health.
I authorize the setting up of my dental file, the follow-up, as well as my registration on the recall list(s) of the treating dentist(s).
I have been informed that my file will be kept in the office at all times and that only the dentist(s) and his/her (their) auxiliary personnel will have access to it.
I acknowledge that I have read the answers to the above questionnaire and that I have taken the customary measures, as the case may be.