I certify that I have read and understand the information given to me. I understand that providing incorrect information can be dangerous to my health; the questions have been accurately answered. I authorize the dentist to release any information, including diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay insurance benefits otherwise payable to me, directly to the dentist or dental group. I understand my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on my behalf or my dependents (including broken appointment fees, late fees, collection agency, and/or attorney fees). I acknowledge that I have received and read a copy of the privacy practices and welcome policies.