I, the undersigned, certify that I have provided an accurate and complete medical / dental history and have not
knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any ques-
tions regarding my medical / dental history. Should there be any changes in my health status in the future, I will
advise the dental ofce. I authorize the dentist to perform diagnostic procedures as may be required to determine
necessary treatment. I understand that information provided from or to my medical doctor or another health care
provider may be necessary, and consent to the release of this information. I understand that responsibility for pay-
ment of the dental services for myself and my dependants is mine, and I assume responsibility for fees associated
with these services.