Medical Form

To avoid complications, it is important to warn us immediately when the state of your health changes.

I, the undersigned, certify that the medical and dental information provided are true and complete and that I did not consciously omit any information. I also consent that my doctor or pharmacist be contacted if necessary, as some of this information may be required for my dental care. I hereby vow to advise you of any change in the state of my health. I, the undersigned, consent to the dental and surgical procedures that are needed or desirable for me, including the use of local anaesthetics, and I will take responsibility for the payment of the fees associated to those procedures. . Furthermore, I authorize the clinic to add my name to the callback list of case dentists. I have also been informed of my right to consult my file, to demand rectifications, and to be removed from the callback list.