I have disclosed my health history information, including allergies, reactions to medicine, diseases, and past procedures. I understand that withholding this information may affect the outcome of my dental treatment at Sunrise Dental.

Consent for Treatment: I, the undersigned patient, or legal guardian of the patient, hereby consent to dental examinations and treatment as deemed necessary by the dentist. I understand that during the course of treatment, additional procedures may be necessary.

In case of emergency: I authorize any necessary life-saving procedures to be performed in the event of an emergency. I understand that a blood transfusion may be a part of a life-saving procedure and give my consent for necessary blood work. I give my consent for the administration of any medication that may be required as a life-saving measure.

Financial Agreement: I understand that the dental office is collecting payments directly from my insurance company as a favor to me. I am responsible for charges not covered by insurance and agree to pay for services at the time of treatment. If the dental office has not received payment from the insurance company within three months of the treatment date, I will accept responsibility for any balance that is brought to my attention.

Release of Records: I authorize the release of my dental records to other healthcare providers as necessary for my ongoing care.

Photographs: I consent to the taking of intraoral and extraoral photographs for diagnostic and educational purposes.

Communication Authorization: I authorize Sunrise Dental to contact me via phone, text message, email, or mail for appointment reminders, billing matters, and other communications related to my dental care.

I confirm that I understand this form and the information contained therein.