Patient Information (Please fill all the fields with the accurate info)

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* Please provide your Government ID to verify the Date of Birth at Dentist Office

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GENERAL RELEASE: I, the undersigned, understand that the information contained in the dental and medical history portion of this chart is important to my treatment. I certify that all the information 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 provider as required by this dental office. I authorize this dental office to perform diagnostic procedures as may be required to determine perform necessary treatment. I understand that it is my responsibility to pay for dental treatment for both myself and my dependants. i assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.