I verify that the above information is factual and true to the best of my knowledge. I authorize the doctor to employ X-Rays, photographs, anesthetics, medicines, surgeries, and other equipment or aides as he.she deems necessary inn order to provide the proper patient care. I understand that payment, proof of insurance, and/or copay is due at the time of service.
I authorize this office to apply benefits on my behalf for the covered services rendered. I cerify that the insurance information I have provided is factual and correct.