2352 Middlefield RD Unit 104 Markham ON , L3S 4T6
In an effort to serve you better, we would ask that you complete the following. We will be glad to assist you PLEASE PRINT.
I, the undersigned, understand that the information contained in this medical and dental history is important to my treatment. I certify that all the information I have completed is correct and that I have not knowingly omitted data. I consent to the release of the medical information from my medical doctor or other health care provider as is required by this dental office. I authorize this dental office to perform any diagnostic procedures as it may be required to determine any necessary treatments. I understand that it is my responsibility to pay for dental treatments for both myself and my dependents. I assume all responsibility for fees associated with my dental treatment or dental diagnostic procedures.