Medical History (This information will remain confidential)
I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment. I certify that all the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.
I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.
By checking this checkbox, I hereby understand and agree to the conditions of treatment and payment mentioned above.