:
:

Responsible Party / Billing information

:

Insurance information

:

 

I hereby authorize Mark Sodorff DDS and Laura Wiison DDS to administer any treatment and to perform such x-rays, anesthetics, and dental procedures as may be deemed necessary or advisable in the diagnosis and treatment of my dental condition.

I authorize release of any information relating to this claim. I realize that I am ultimately responsible for all costs of dental treatment.

I hereby authorize my insurance benefits to be paid directly to Mark DDS and Laura Wilson DDS.

Alter initial x-rays and examination, we will give you an estimate of fees to cover your treatment. At that time financial arrangements will be made before treatment is rendered.

Preferred method for payment

Medical History

To the best of my knowledge, all of the following answers are correct If my health or medications change, I will inform Mark DDS and Laura Wilson DDS at my next appointment.

Others:

Have you ever had any of the following? (Please check all that apply)

Recreational use combined with local anesthesia may cause a life-threatening emergency.


DENTAL HISTORY

Nearest Relative

CANCELLATION POLICY