Clerical Information Update

Sein H. Siao, D.M.D. and Associates

Please correct the errors described below.

[For your convenience, you will receive your appointment reminders via text and/or email. Please provide us with your most current information.]

If yes, please fill in the following information and present new insurance card (if available) to the front desk.

Permission for Dental Examination and Treatment

I do hereby authorize and consent to any x-rays, examination, anesthetic, or dental treatment rendered under the general, direct, or indirect supervision of Dr. Siao and/or staff members they may deem necessary. This authorization will remain in effect until cancelled in writing by me. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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