In order to aid in evaluating your dental health thoroughly and completely, please complete the following examination questionnaire. This will become part of your office record and will be held in strict confidence.
I, the undersigned, certify that I have provided an accurate and complete personal and medical - dental history and have not knowlingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical - dental history. I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required and I consent to my physician being contacted if necessary. I have also reviewed the privacy policies of the office regarding protection of my personal information. I understand that the responsibility for payment for the dental services provided for myself and or my dependants is mine and I will assume responsibility for fees associated with these services. I authorize release, to my dentist, information and authorize direct payment contained in claims submitted electronically.
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