Patient Info

ASSIGNMENT AND RELEASEI certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr.

all understand insurance that benefits, I amif the financially use of my responsible signature for on all all charges insurance whether or submissions. not paid by insurance. I authorize The such information above-named to the dentist may above-named use my health Insurance care Company(ies) information and and may their discloseagents for benefits the or purpose the of benefits obtaining payable for payment related for services services. and This consent determining will end insurance when my current treatment plan is completed or one year from the date signed below.

INCASE OF EMERGENCY, CONTACTSpecify someone who does not live in your household.

How often do you floss?