I hereby state that, to the best of my knowledge, the above information is true and accurate, complete to my satisfaction, and that I will not hold the dentist or the staff responsible for any errors or omissions in the completion of this form.

I authorize the release of any information related to my health care or to my claims.  I understand that I am financially responsible for the costs related to treatment.  I authorize payment of my benefits, otherwise payable to me, directly to Palm Beach Center for Periodontics & Implant Dentistry, P.A. and I authorize the use of the signature on all insurance submissions.