Have you ever experienced any of the following problems in your jaw?
Consent, Authorization, and Release
I certify that I have read and understand the information to the best of my knowledge. The questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I will not hold my dentist, or any other member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. I authorize the dentist or staff to perform all dental services that I or my child/dependent may need. I authorize the dentist to release any information including the diagnosis and the record 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 directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that it is my responsibility to know the terms of my dental insurance contract (i.e. How often my insurance carrier will pay for exams and cleanings). This consent shall remain in full force and in effect until canceled by either party.
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