Provider Terms and Conditions Acknowledgement

I AGREE THAT I AM A LICENSE PROFESSIONAL AND ALL THE INFORMATION SUBMITTED IN THIS FORM IS TRUE. I AM CREDENTIALED AND LICENSED IN MY STATE TO PROVIDE ORAL HEALTH CARE. I UNDERSTAND THAT I AM RESPONSIBLE FOR THE FINAL OUTCOME OF ALL MY CASES AND I WILL PROVIDE THE STANDARD OF CARE THAT HAS BEEN DELEGATED TO ME BY ALL MY PATIENTS