I certify that I have read and understand the above information. The above questions have been accurately answered. I understand that providing incorrect
information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or
examination rendered to my child or me 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. I understand
and agree that if charges are not paid when due, interest will be charged on the overdue balance at the rate of one and one-half (1 ½ ) percent per month,
and if dentist undertakes any collection action, I will be responsible for costs of collection, including reasonable attorney’s fees.