medical questionnaire

Please answer the following questions.

All information will be treated with complete professional confidentiality.

Booking Cancellation Policy

24 hours notice is required if you are to cancel your appointment. If you fail to attend your dental appointment you will incur a $50 cancellation fee. Terms of payment – payment is required by completion of treatment, unless otherwise arranged. In the event that payment is not forthcoming, you will be responsible for all expenses including debt collection, interest, legal fees incurred by And Smile Dental in collecting such amounts. I accept the above terms and conditions. I acknowledge that I am the person responsible for this account and that all of the information provided on this is true and correct.