Please circle yes/no to which of the following you may have had in the past or have at present.
I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider, who may release such information to you. I will notify the dentist of any changes in my health or medication.
I give permission the dentist and their staff to take photographs, X-rays, models and other diagnostic aids deemed appropriate to make a thorough diagnosis. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
In connection with dental services, I agree and consent to allow the photographs and videos taken before, during and after completion of my dental treatments to be used for dental records, research, education, public relations, patient counseling or other purposes. I further agree and consent that the photographs relating to my dental care may be published and republished either separately or in connection with each other in dental photo albums, professional journals or dental books
I agree to the terms and conditions listed above