Patient Information

1. I certify that the information provided is accurate and will be used to grant credit and provide dental service. I understand that I am financialy responsible for all charges not covered by or paid by my insurance for any reason. 2. By signing below, I authorize that you may verify and exchange information onme and any additional applicants, including reports from credit reporting agencies. 3. I authorize payment directly to the dentist of any group insurance benefits otherwise payable to me. I understand that I am financially responsible fir all charges not covered by this autorization. I authorize release of any information relating to any dental claim(s). 4. I understand that this dental practice is owned and operated by an independent dentist. I acknowledge that each dentist is individualy responsible for the dental care provided to me and to other dentist or corporate entity is responsible for my dental treatment.