I have seen my Denture(s) or Partial(s) or Veneer(s) or Crown(s) in wax (if applicable) today and approve of its appearance, including shade, shape, size, ad position of artificial teeth and their relationship to my natural teeth (if any).

I am aware that this office will not be responsible for any further changes in the color, shape or position of the teeth.

If I request any changes relating to the above described appearance, I will bear the financial responsibility.