I understand the information I have given is correct to the best of my knowledge, and it will be held in the strictest of confidence by this office. It is my responsibility to inform the dental staff of any changes in the medical status. I authorize the doctor to perform any necessary dental services with my informed consent that may be needed during diagnosis and treatment. I also understand that this office reserves the right to verify the credit status of potential patients and /or parents of patients prior to extending credit for treatment fees. I acknowledge receipt of this office's notice of Privacy Practices.