I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my child’s medical status.
This office reserves the right to verify the credit status of potential patients
and / or parents of patients prior to extending credit for treatment fees and
may, at the discretion of the office, use the services of one or more credit
I authorize the dental staff to perform any necessary dental services my child may need.