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 health. I authorize the dentist to release any information including the diagnosis and records of any treatment or
examination rendered to me or my child during the period of such Dental care to third party payer’s and/or health practitioners. I authorize and request my insurance
company to pay directly to the dentist tor dental group insurance benefits for the payment of all services rendered on my behalf or dependants.