1. I hereby authorise the dentist or designated staff to take x-rays, study models, photographs, and other
diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis.
2. Upon such diagnosis, I authorise the dentist to perform all recommended treatment mutually agreed upon
by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anaesthetics, sedatives and other medication as necessary. I fully understand that using
anaesthetic agents embodies certain risks. I understand I can ask for a complete recital of any possible
4. I agree to be responsible for payment of all services rendered on my behalf and on behalf of my
dependents. I understand that payment is due at the time of service unless other arrangements have been
Dr A. Jay Lo
29 Owen Street P.O.Box 1057 INNISFAIL Q 4860
(07) 4061 1134
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