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.