I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child's medical status.

I authorize the dental staff to perform the necessary dental services my child may need.

The parent or guardian who accompanies the child is responsible for payment at time of service unless prior arrangements have been approved.

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Doctor's Signature

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Date