To the best of my knowledge, all of the preceding answers are true and correct. If there is ever any change in my child’s health or if my child’s medicines change, I will inform the doctor of dentistry at the next appointment without fail.
I acknowledge by signing this form, I will be financially responsible for my child’s account.
I hereby authorize DR. MAHNAZ GORGANI, DR. NATALIE VANDER KAM and/or their associates to perform any and all treatment for my above named child and consent to such methods, drugs, and agents as may be indicated in connection with his/her dental care. This consent shall remain in effect until cancelled