Although dental personnel primarily treat the area in and around your mouth, it is part of your entire body. Health problems that you may have or medication… [content missing]
I affirm that the information given is correct to the best of my knowledge. I understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
I also authorize my insurance carrier to issue the dental benefits of my plan directly to this dental office. In addition, I authorize release of any information necessary to process dental insurance. I understand that I am responsible for any portion my insurance carrier does not pay.