I hereby authorize the dentist or designated team member to take an x-ray, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis. Upson such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anaesthetics, sedatives and other medication as necessary.
I fully understand that using anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible complications.
I agree to be responsible for payment of all services rendered on my behalf and on behalf of my dependents. I understand that payment is due at the time of services unless other arrangements have been made.
I understand that I will also be liable for any costs associated with the collection of any outstanding monies.
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