CONSENT FOR TREATMENT: I cerify that all questions have been accurately answered. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to me, or my child, to third party payors and/or health practiotioners. I authorize and request my Insurance Company to pay directly to the dentist, insurance benefits otherwise payable to me. I hereby give permission to Anshu S. Kumar-Gauba, D.D.S. and staff to administer treatment and to use anesthetics, necessary to perform such procedures that may be needed or advisable for diagnosis and treatment.
YOUR SIGNATURE BELOW SIGNIFIES YOUR UNDERSTANDING AND WILLINGNESS TO COMPLY WITH THESE POLICIES.