Release Form

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.

I authorize the release of any information concerning my or my child's healthcare, treatment, and advice provided for the purpose of evaluating and administering claims for insurance benefits.

I authorize the release of any information concerning my or my child's healthcare, treatment, and the advice provided to another dentist.

I understand that if financing is required, credit bureau reports may be obtained.

I understand that I am responsible for all costs of dental treatment.

I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me.