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Founders Park Dentistry

By my signature above, I consent to the examination and treatment by Founders Park Family Dentistry. I
understand that dentistry is not an exact science and therefore the results of any treatments performed may
vary from patient to patient. I understand that occasionally, additional treatment may be required. Also, by my
signature below, I herby certify the correctness and completeness of the medical history information above.
I certify that the information provided by me on this Medical Dental history form is correct and complete to the
best of my knowledge. I will advise the office of any future changes.[wp_e_signature_sad doc="10"]

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