I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history. I have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers regarding this medical-dental history.
Should there be any change in either my health status or any other information I have provided, I will advise the dental hygienist.
I authorize the provider (dental hygienist) to perform dental hygiene diagnostic procedures as may be required to determine necessary treatment.
I understand this action will give my consent verbally.
I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the dental hygienist, or dental information provided from or to my medical doctor, dentist or other health care provided as needed may not be encrypted. Despite this, I agree to communicate with the dental hygienist and give permission to the dental hygienist to correspond through a phone call or email communication if necessary with by dentist/doctor/health care provider with a full understanding of the risk.