I authorize Dr. Speer and his staff to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis. I also authorize Dr. Speer to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand that the use of anesthetic agent, medications, and some dental procedures embody a certain risk. I authorize my insurance company to pay Oak Grove Dental Center all the insurance benefits for services rendered. I also authorize the release of all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not they are covered by my insurance. I also acknowledge that my payment is due at the time of treatment.