(Please note any medications prescribed, for your oral surgical care may interfere with the action of birth control pills
Permission is hereby granted to the staff of this office for such procedures and anesthesia as may be necessary for the care of the undersigned patient. Permission is granted to release my medical-surgical records to my primary Dentist or Physician. I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist responsible for any errors or omissions that I may have made in the completion of this form.