I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there are any changes in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for the services rendered. I authorize the use of the signature on all insurance submissions
I authorize the dentist to release all information necessary to secure the payment of benefits. I understand I am financially responsible for all charges that were or not paid by insurance.