I understand that I have come to the office of Frank C. Greider, M.S., D.D.S., P.C. for routine dental treatment and I do hereby give my consent for this treatment. I have been advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the results or as to cure. Fees are guaranteed for 12 months from the date of this statement.

I hereby state that I have read and understood this consent, and that all questions about the procedures have been answered in a satisfactory manner.

I certify that I explained the above procedures to the patient and/or legal guardian before requesting their signature.