I understand that the information I have provided is correct to the best of my knowledge and it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I hereby authorize release of any information related to insurance claim. I consent to examination and treatment as advised by the doctor. Payment is due when services are rendered. Alternate payment arrangements must be made in advance of treatment. Payment methods include VISA, MasterCard, Direct Debit and cash.