RESPONSIBILITY AND CONSENT STATEMENTS

Terry J. Gillespie, D. D. S.

1700 Summit

Red Oak, Iowa  51566

(712)623-5404

 

 

          I hereby authorize and request the performance of dental services for myself or for:

 

_____________________________Age______

_____________________________Age______

_____________________________Age______

_____________________________Age______

_____________________________Age______

_____________________________Age______

 

          I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for diagnostic purposes or dental treatment.

 

          I understand and acknowledge that I am financially responsible for the services provided for myself or the above named, regardless of insurance coverage.

 

__________________________  Date_______

(Signature of Responsible Party)