Consent for Treatment

This is to certify that 1, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic as indicated. I fully understand the office policy and will assume responsibility for fees associated with those procedures performed. I also consent to the use of my email address (when provided above) and email to communicate with myself, my insurance company, dental offices, or specialists in the sending of receipts, statements, estimates, x-rays, and any information requested by such for the process of predeterminations, claims or updating records.