GENERAL RELEASE

I, the undersigned, understand that the information contained in the medical and dental history is important to my treatment.I certify that all or 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 dependent

First Visit Paperwork