Consent and Certification

By submitting this form to Bright Horizons Dental, I authorize Bright Horizons Dental to collect, review, and use the medical and personal information I provide for the purpose of evaluating my dental care and treatment needs.

I understand that the information submitted through this form may include protected health information. By submitting this form, I confirm that I am providing this information voluntarily.

I certify that the information I have provided is true, complete, and accurate to the best of my knowledge.