Primary Dental Insurance
Secondary Dental Insurance
I give my consent for examination and treatment.
I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.
NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.