Check all that are applicable, either now or in the past:
The answers to the health questions are accurate and complete. I will notify Dr. Okubo of any change in my health information or medications at subsequent appointments. Before X-Rays are taken I will inform you if I am Pregnant or might be. Dr. Okubo’s HIPAA policy has been made available. I authorize Dr Okubo to perform an exam, radiographs and treatment. I authorize the release of my dental and medical records to Dr. Okubo