I (or authorized representative/guardian) hereby authorize Costa Family
and Cosmetic Dentistry 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
Costa Family and Cosmetic Dentistry 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.