By typing my name in the box below, I certify that I have read and I understand the questions above and have completed this form to the best of my knowlege. I will not hold my surgeon, or any other member of his staff, responsible for any errors or omissions I have made in the completion of this form. Further, I consent to the performing of the oral surgery procedures agreed to be necessary or advisable for myself; or for someone else if I am their legal guardian/substitute decision maker. Also, I will assume responsibility for the fees associated with the procedures.