Thank you for visiting Gold Coast Family Dental. We want your visit to be pleasant and comfortable. Please fill out this form completely. The better we communicate, the better we can care for you.
TREATMENT AUTHORIZATION FORMS
I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.
Payment for all treatment and services rendered are my responsibility