I, the undersigned, being the patient, parent or guardian of the above
minor patient, consent to the performing of whatever procedure may be determined
necessary or advisable, in the opinion of the Doctor. A report of treatment
will be sent to my referring dentist. I also understand that upon completion
of root canal therapy in this office I will be referred to my general dentist
for permanent restoration such as crown, cap, jacket, onlay or filling.
I understand that the total payment of the dental service is my responsibility
and not that of the insurance company. Payment is due when services are