I hereby declare to have read, understood and have answered the survey dentalmed above to the best of my knowledge. I hereby undertake to advise you of any change in my health. I authorize the constitution of my dental records, monitoring as well as my entry on the recall list (of) dentist (s) contractor (s). I was informed that my dental records will be kept at the office at all times and that (the) dentist (s) and its (their) support staff will (have) one (s) access. I was also informed of my right to see my file, to request a correction.Signature:
I have read the answers to the questionnaire.Signature:
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