I, the undersigned, certify that I have provided an accurate and complete personal and medical/dental history and financial information, and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any
questions regarding my medical/ dental history. Should there be any change in either my health status or any other information I have provided, I will advise the dental office at once. I authorize the dentist to perform diagnostic procedures as may be required to determine the necessary treatment. I also authorize the dentist to take X-rays, study models, photographs or any other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of my dental needs. I also authorize the dentist to perform any and all forms of treatment, medication and therapy, I consent that X-rays and photographs to be used by Dr. Khafaji and his associates for education purposes. I understand that information provided from or to my medical doctor or another health care provided may be necessary. I have been advised of the privacy of the office and that my personal information will be collected, used and disclosed within the guidelines of the policy. I understand that the responsibility of the payment of dental services for myself and my dependents is mine, and I assume responsibility for fees associated with these services, and these fees are due and payable at the time services are rendered, unless a financial agreement has been made.