I verify that the above information is factual and true to the best of my knowledge. I authorize the doctor to employ X-Rays, photographs, anesthetics, medicines,
surgeries, and other equipment or aids as he/she deems necessary in order to provide the proper patient care. I understand that payment, proof of insurance, and/or
copay is due at the time of service.
I authorize this office to apply benefits on my behalf for the covered services rendered. I certify that the insurance information I have provided is
factual and correct.
