By signing, I understand that, to the best of my knowledge, all of the proceeding answers are true and correct. If I ever have any change in my health or medications, I will inform my health care provider immediately. I hereby give my consent to treatment for myself (or the named patient of whom I am the parent or legal representative) to Bowery Dental.

I also agree to inform the office at least 48 hours prior if I need to make changes to my scheduled appointment. I understand that a $50 charge will be incurred for any changes or missed appointments without 48 hours notification.

Upon submission of this form, you will be directed to review our notice of privacy practices and your health information rights.