To the best of my knowlege, the question on this form have been accurately answered. I under stand that providing incorrect information caon be dangerout to my (or patient's) helath It is my responsiblity to inform the dental office of any changes in medical status.
I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Cleveland Dental all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.