Although dental personnel primarily treat the area in and around your
mouth, your mouth is a part of your entire body. Health problems that you
may have, or medication that you may be taking, could have an important
interrelationship with the dentistry you will receive. Thank you for answering
the following questions.
I certify that I have read and understand the above information to the
best of my knowledge. The above questions have been accurately answered.
I understand that providing incorrect information can be dangerous to my
(or patient's) health. I authorize the dentist to release any information
including the diagnosis and the records of any treatment or examination
rendered to me or my child during the period of such dental care to third
party payors and/or health practitioners. I authorize and request my insurance
company to pay directly to the dentist or dental group insurance benefits
otherwise payable to me. I understand that my dental insurance carrier
may pay less than the actual bill for services. I agree to be responsible
for payment of all services rendered on my behalf or my dependents.