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The following information is required by the dentist to assist in proper diagnosis and treatment.
Privacy Act Notification: I have been informed of the privacy policy of this office and understand that all information I have supplied will be used and disclosed as set out within this office policy.
Office Policy: Your appointment time will be reserved for you. Otherwise, a short-notice/ cancellation fee of 75$ may apply without a 48hour notice made.
Patient Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorize the dentist to perform diagnostic procedures and treatment may be necessary for proper dental care. I also understand that consultation with my medical doctor may be required, and I consent to my physician being contacted as necessary. I understand that the responsibility for payment for the dental services provided for myself and my dependents is mine, and I will assume responsibility for fees associated with these services.
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