• I have read and I understand the above questions. I will not hold Dr. Henry or any member of his staff responsible for any errors or omissions that have been made in the completion of this form. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any later changes to the history record or medical/dental status. We will discuss your child's treatment with parents/legal guardians/person(s) financially responsible for his/her treatment and referring doctors/dentists for the furtherment of his/her treatment.
  •