Masci, Hale & Wilson

New Patient Packet

Step 3 — Medical Information

Conditions

Allergies — Are you allergic or have you had a reaction to:

Signatures

I understand and authorize Drs. Masci and Hale and associates to perform and/or administer any and all forms of treatment, medication and anesthesia that may be necessary. I will not hold my dentist, or any member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I certify that I have read and understand the above.