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I, the undersigned, certify that I have provided an accurate and complete medical history and have not knowingly omitted any Information.
This is to certify that I, the undersigned, understand and agree with what I have read and consent to the performing of the dental procedures agreed to be necessary or advisable, including the use of local anesthesia. I agree to make payment for service upon completion, of each appointment, by cash, cheque or credit card unless other arrangements have been previously and specifically made with the dentist.
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