I, the undersigned, certify that I(or my dependent)
have the insurance coverage stated and assign directly to Dr. Thomas W. Barron, D.M.D., PA all insurance benefits, if any, payable to
me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. I hereby
authorize Thomas W. Barron, D.M.D., PA to release all information necessary to secure payment of benefits. I autorize the use of
this signature on all insurance submissions.
Please answer the following questions by circling yes or no. This information is for our office records only and Will be kept confidential. A complete and thorough history is vital for a proper orthodontic evaluation.