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Please print this form, fill out all the applicable fields and then proceed to the next form.

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient)
   's dental needs.

2. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3. I agree to the use of anesthetics, sedatives and other medication as necessary.  I fully understand that using anesthetic agent embodies certain risks.  I understand that I can ask for a complete recital of any possible complications.

4. I agree to be responsible for payment of all services rendered on my behalf or my dependents.  I understand that payment is due at the time of service unless other arrangements have been made.  In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account.  If required, I also understand a check of my credit history may be made.

Date:   Witness:
   Patient Signature or Legal Guardian            MM/DD/YY
 

  Relationship to Patient:
Parent/Responsible Party's Signature

NOTE: Please print this form, fill out and either mail it to our office, fax it to our office or bring it in when you come in for your appointment.  Remember to fill out all 5 forms.