I hereby authorize my insurance benefits to be paid directly to my dentist. I am financially responsible for any balance due and authorize the dentist to release any information for this claim. I authorize that my records can be used by my dentist if he so determines. In consideration of the services rendered to me b this dental office, I am obliged to pay said office in accordance with its credit terms and policy.
I consent to making videotapes, photographs, and x-rays before, during, and after treatment, and to use the same and to use the same by the doctor in scientific papers and demonstrations.
I certify that I have read or had read to me the contents of this form and realize the risks and limitations involved.