I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical question.
I authorize Dr. Alexandra Ociepa and her team to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care. I understand that I am financially responsible to the dentist for the dental services provided.
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I consent to the collection, use and disclosure of my personal information by Mint Leaf Dental as set out above in the information about the office's privacy policies.
In compliance with Canadian Anti-Spam Laws, I understand that by signing this form, I give Mint Leaf Dental permission to send me information such as appointment reminders/confirmations, follow-up, news and events. I can opt-out from these emails at anytime by notifying any of the team members at Mint Leaf Dental.