This is to certify that I, the undersigned, consent to the performing of whatever dental services and/or surgical procedures may be decided upon to be necessary or advisable, and to the use of local anesthetic as may be deemed advisable by the dentist. I hereby authorize my dentist to release any and all dental and medical information to the above-named insurance carrier(s) for the purposes of claims administration and evaluation, utilization review and financial audit. This authorization remains valid and effective from the date of signing until revoked in writing. I hereby authorize my Insurance Carrier to pay directly to the within-named dentist(s) the dental benefits otherwise payable to me. I understand that I am financially responsible for any charges not covered by insurance. I acknowledge the office policy that I must give forty-eight hours notice, during business hours, to change or cancel an appointment. Failure to do so may result in a charge to my account.