General Consent to Treatment:
I agree and consent to a dental examination and understand that additional diagnostic procedures and dental treatments may be recommended and will be discussed with me prior to being done. I acknowledge that there are no guarantees, expressed or implied, as to the results of any procedures or dental treatment performed.
Release of Information:
I authorize Dr. Katz, Theberge, Coleman and Pham to release any information regarding my dental/medical history, diagnosis or treatment to third party payers and/or other health professionals.
Acknowledgement of Receipt of Notice of Privacy:
I have received a copy of this office's Notice of Privacy Practices
Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient is physically or mentally incapable.
I hereby state that the above health questionnaire has been answered to the best of my knowledge.
I authorize the release of information.
I understand and agree to the General Consent to Treatment.
I acknowledge receipt of notice of privacy.