520 Franklin Avenue, Suite 121
Garden City, NY 11530
1. The undersigned hereby authorizes the doctor to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor for a thorough diagnosis of the patient’ dental needs.
2. I also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate mediation and therapy indicated for such treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with (name of patient) . I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize, and consent hat the doctor choose and employ such assistance as deemed fit to provide recommended treatment.
3. To the best of my knowledge, the above information is complete and accurate. I understand that even though I may have some type of dental insurance coverage, I am responsible for payment services rendered. I authorize release of any information to me insurance company related to my dental claims.
SEMIANNUAL REVIEW OF MEDICAL-DENTAL HISTORY: If history remains essentially unchanged, sign below
To the best of my knowledge, the above information is complete and accurate.