Thank you for visiting our office. We want your visit to be pleasant and comfortable. Please help us by completing this form.
All of this information is completely confidential.
I have reviewed the information on this form and it is accurate to the best of my knowledge. I authorize and give consent for the dentist and/or team of this office to perform dental services as agreed between doctor and patient and/or guardian, including the use of local anesthetic and other medication as indicated.
|Signature (Parent/Guardian if under age 18)
||Relationship (if patient is under age 18)