I, consent to be treated at the office of Joseph A. Geleris, D.D.S.. I understand that all treatment-will be performed by licensed personnel who are skilled in their respective professions.I understand that any and all treatment will be thoroughly discussed prior to its administration. I understand that the treatment of a minor in my care will be discussed with his or her parent or guardian prior to its administration.I understand that the cost of treatment and patient's insurance will be discussed at the time treatment is proposed. The office will do its best to inform me of my dental insurance coverage and of my responsibility for co-payment. In spite of the difficulty of predicting exact dollar coverage of insurance, predetermine benefits as I direct and inform me of my benefits. I will ultimately be responsible for the cost of my dental care.I understand that if I have any questions or concerns, the office manager will gladly attempt to resolve any issues that regard treatment or fees.I am aware of the “Patient Privacy Act” which assures the privacy of my dental records.I agree to inform the office of any changes in my medical conditions including any medications I am taking.