I authorize Penrod Dental Care to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or other health practitioners.
I authorize and request my insurance company to pay directly to Penrod Dental Care insurance benefits otherwise payable to me.
I consent to the dental practice using my home, cell, work and email to contact me regarding appointments, treatment, insurance and my account.
I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents