I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is a change in my medical status, I will inform the dentist.
I authorize the insurance company indicated on this form to pay the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.
I authorize the dentist to release all information necessary to secure the payments of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Payment is due in full at the time of treatment, unless prior arrangements have been approved.
The Truth Behind Fluoride