I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to determine appropriate and healthful treatment. If there is any change in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay to dentist all insurance benifits otherwise payable to me for services rendered.
I authorize the use of this signature on all insurance submissions
I authorize the dentist to release all information necessary to secure the payment of benifits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Payment is due in full at time of treatment, unless prior arrangements have been approved