I UNDERSTAND THE ABOVE INFORMATION IS NECESSARY TO PROVIDE ME WITH DENTAL CARE IN A SAFE AND EFFICIENT MANNER. TO THE BEST OF MY KNOWLEDGE, ALL OF THE INFORMATION ON BOTH SIDES OF THIS FORM IS TRUE AND CORRECT. IF THERE IS ANY CHANGE IN MY HEALTH OR MY MEDICATIONS, I WILL INFORM THE DOCTOR PRIOR TO ANY TREATMENT.
I AUTHORIZE THE DOCTORS AND/OR THEIR STAFF TO TREAT THE ABOVE NAMES PATIENT. I WILL CONTACT THE DOCTORS OFFICE IF I HAVE ANY ADDITIONAL QUESTIONS OR THERE ARE ANY UNEXPECTED REACTIONS TO TREATMENT. I REALIZE THAT THE RESULTS OF CERTAIN PROCEDURES CANNOT BE GUARANTEED.
ALL FINANCIAL ARRANGEMENTS WILL BE MADE PRIOR TO TREATMENT AND I REALIZE THAT THE FEE ESTIMATE LISTED FOR DENTAL CARE IS ONLY VALID FOR SIX MONTHS. I HAVE BEEN GIVEN, READ AND UNDERSTAND THE HIPAA, FINANCIAL & OFFICE POLICIES ACKNOWLEDGEMENT FORM UNDER SEPARATE COVER.
I HAVE READ AND FULLY UNDERSTAND THE CONDITIONS OF TREATMENT AS STATED ABOVE.