Form

DELIVERY

have seen the crown/ bridge/ partial/ denture/ night guard and am satisfied with the color and fit of it. I am satisfied with the treatment at the time of insertion. If changes are made later by patient, I the patient will be responsible for lab fees.

(for the warranty to be valid, checkups and cleanings every 6 months must be required by the patient.)

I am aware that treatment is guaranteed for 5 years as long as I continue to come in to Antoine Dental Center for my routine cleaning every 6 month. Cost of cleaning is not included.

Signature

Date

First Name

Last Name

Date Of Birth