General Release: I, the undersigned, certify that I have provided an accurate and complete personal and medical-dental history and have not knowingly omitted any information. I have had the opportunity to ask questions and receive answers to any questions regarding my medical-dental history. I authorise the dentist to perform diagnostic procedures as may be required to determine necessary dental treatment. I understand that information provided from or to my medical doctor or another HealthCare provider may be necessary and I consent to the release of this information. I understand that responsibility for payment of dental services for my dependants and myself are mine, and I assume responsibility for fees associated with these services. I am aware of and understand that payment is required at the end of each appointment, and that if an account is sent to me, I will incur a $10 management fee. I am aware that if I fail to attend an appointment, there will be a $50 per half hour failure fee or if my account is sent to a Debt Collection agency, I will incur a 25% additional fee of the amount owed.