I verify that the above information is factual and true to the best of my knowledge. Iauthorize the doctor to emloy X-Rays, photographs, anesthetics, medicines, surgeries and other quipment or aids as he/she deems necessary in order to provider the proper patient care. I understand that payment, proof of insurance and/or copay is due at the time of service.
I authorize this office to apply benefits on my behalf for the covered services rendered. Icertify that the insurance information I have provided is factual and correct.