Please complete all information if diferent from above
This signature authorizes payment of my account on the above card
Indicate which of the following you presently have, or have ever had: (Please check all that apply)
Are you allergic to or have you reacted adversely to any of the following medications?
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.