New Patient & Dental History Form

To complete only if the patient is under 18 years old

• I, the undersigned, consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of local anaesthetics as indicated and I will assume responsibility for the fees associated with those procedures.

• I understand that the practice requires at least 48 hours notice if I need to cancel my scheduled appointment and hat a cancellation fee may apply.

• I am aware that payment is required on the day of treatment.

• We provide as a courtesy to our patients a preventative recall program that offers a recall reminder if you have not been to the practice in 6 months.