*Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. We are allowed to release this information to your insurance company or as necessary to get paid for our services. You can have access to your records by simply asking. By agreeing with this consent form, you permit the release of any information to or from your dental practitioner as may be required.

Please complete all portions of this paperwork before submitting it to your dental practice. There is a NO TO ALL selection available on the medical questionnaire to assist you in quickly completing that tab. You can then go back and select YES to the options that pertain to your child as needed. 

By submitting these forms you certify that they were completed thoroughly and to the best of your knowledge.