Child's Information
First Parent's Information
Second Parent's Information
Child's Residential Status
First Parent's Dental Insurance Information
Second Parent's Dental Insurance Information
Assignment of Benefits

Assignment of Benefits: I hereby authorize payment directly to the above named dentists of the group dental benefits otherwise payable to me but not to exceed the charges shown on the claim. I understand that I am financially responsible for 100% of all charges and any charges not covered by this authorization.

All balances past due 60 days are subject to a finance charge of 1.5% per month (an annual rate of 18%) and/or subject to all legal and collection expenses.

Medical Information
Dental Information

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my child’s health. It is my responsibility to inform the dental office of any changes in my child’s medical status. I also authorize the dental staff to perform the necessary dental services that my child may need. I also authorize the dentist to release any information including the diagnosis and the records of the treatment or examination rendered to my child during the period of such care to third party payers and/or other health practitioners. I further acknowledge the receipt of the Dental Materials Fact Sheet dated October 2001 and HIPPA Privacy Form.

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