Please list any medications now being taken by patent (including supplements, herbal and non-prescription. ) Type “none” if applicable.

I AUTHORIZE Dr. Baby and Dr. Rojas and/or their staff to perform diagnostic procedures and treatment as may be necessary for proper dentofacial care. I authorize release of any information concerning my (or my child’s) health care for advice and treatment to and from interdisciplinary team members. I understand that where appropriate, credit bureau reports may be obtained. I authorize the taking of photographs, radiographs and other diagnostic records before, during and after treatment and to the use of the same by the doctor. The information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office on any changes in my medical status. *