I, the undersigned, declare that I have read, understood, and answered the above medical-dental questionnaire to the best of my knowledge. I hereby undertake to notify you of any change in my health status. I authorize the creation of my dental file, its follow-up, and my registration on the callback list of the treating dentist(s). I have been informed that my dental record will be kept in the office at all times and that only the dentist(s) and their auxiliary staff will have access to it. I was also informed of my right to access my file, request a change and/or be removed from the callback list.
I agree to receive emails about my treatment plan, insurance papers, appointments or any other relevant information related to my dental records.
I acknowledge that I have read the answers to the registration questionnaire and have taken the appropriate measures where necessary.