RESPONSIBILITY AND CONSENT STATE

RESPONSIBILITY AND CONSENT STATEMENTS

Terry J. Gillespie, D. D. S.

1700 Summit

Red Oak, Iowa 51566

(712)623-5404

I hereby authorize and request the performance of dental services for myself or for:

_____________________________Age______

I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by his supervised staff for diagnostic purposes or dental treatment.

I understand and acknowledge that I am financially responsible for the services provided for myself or the above named, regardless of insurance coverage.

__________________________ Date_______

(Signature of Responsible Party)