I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I also give permission to Dr. Robb Heinrich and his staff to use any photos take for lecturing and continuing education purposes.

I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.