I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination renduced to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may less than the actual bill for service. I agree to be responsible for payment of all services on my behalf or my dependents.
I realize that failure to keep this account current may result in collection activity and agree to pay necessary costs and attorney fees incurred in attempting to collect on this account.