State* (required)
State
State
I, the undersigned, certify that all of the above medical and dental information is true to my knowledge. I have not omitted any pertinent information.
I, the undersigned, will assure responsibility for fees associated with these procedures. Insurance coverage is an agreement between you, the patient and your insurance company. As a courtesy, we can work with your insurance company with a pre-determination in writing from them the ultimate responsibility for payment lies with you the patient.
*We need to obtain a copy of your Driver's License, Social Security Cards, and Insurance Card if Insured. Please Have Then available. Thank you!