Indicate which of the following you have had or have at the present. Check "yes" or "no" for each item.

I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. In the event of non-payment for dental services received, the undersigned agrees to pay all lawyer fees, court costs, and collection fees up to 50%, if turned over to an outside collection agency.