CONSENT FOR SERVICES

I (or authorized representative/guardian) hereby authorize Dr. Costa to take x-rays, study models, photographs
and/or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient's
dental needs. Upon such diagnosis, I authorize Dr. Costa to perform all recommended treatment mutually agreed
upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics,
sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks.
I understand that I can ask for a complete recital on any possible complication. I hereby give Dr. Costa the absolute
right and permission to use my photographs for educational or promotional purposes. The undersigned completely
and forever releases any right to present or future compensation in connection with the use of said photographs.

I have read and understand the above information.

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