I certify that I have read and I understand the questions asked. I certify I have answered these questions in completion and do not hold the practice, doctor(s), or team responsible for any errors or omissions that I have made in completing these forms.

I consent to the diagnostic procedures and treatment by the dentist(s) of this office necessary for proper dental care This form is to disclose Medical History. The above statement seems it should be on its own form for consent.

Signature (Patient or Guardian)