I certify that I, and/or my dependent(s), have insurance coverage with and assign directly to Dr. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payments for services and determining insurance benefits or the benefits payable for related services.

Place a mark on "yes" or "no" to indicate if you have had any of the following:

Physician's Name
Date of last visit

Place a mark on "yes" or "no" to indicate if you have had any of the following:

List any medications you are currently taking and the correlating diagnosis: *

Allergies