I, the undersigned, do hereby authorize and consent to the administration of all dental procedures deemed necessary or advisable for myself, or my child, by the attending dentist, including but not limited to, the use of local anesthetics or other prescribed medications. I shall assume the responsibility for payment of all fees associated with treatment procedures provided. I consent to collection, use and disclosure of my personal information for the purposes outlined in the personal information consent agreement. I have reviewed the foregoing information and consent. I have had the opportunity to ask questions and understand the above consent.