Privacy Policy & Signature
I have accurately completed this medical history form to the best of my knowledge.
I hereby give my authority for dental treatment agreed upon by me, to be carried out by the dentists and staff at the dental practice.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents.
I understand that payment is expected at the time of service unless other arrangements/agreements have been made.
Any information (including x-rays, photos, video, audios) regarding patients is collected and maintained in accordance with State and Federal Privacy Legislation. I understand that my dentist will take images of my teeth and smiles before and after my treatment. I understand these images may be used in a practice portfolio to showcase examples of dental work to other patients and my identity will remain anonymous.
I understand that there is video and audio surveillance on site. Its purpose is to improve doctors consulting skills within the general dental practice. The recording will remain strictly confidential and will never be uploaded or shared without your explicit consent.