18.0 I understand that providing inaccurate information can be dangerous to my child's health. I certify that I have read and understand the above information. I acknowledge that I have answered the above questions correctly and to the best of my ability, and that any questions that I had have been answered to my satisfaction. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Name of Person Completing Form: Relationship to Child: