To the best of my knowledge, the questions on this form have been accurately answered. I am the parent, guardian or personal representative of this patient and have the legal right to authorize medical and dental care for this child. I understand that providing incorrect or incomplete 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 or dental status.

I authorize the dentists and staff of Center For Pediatric Dentistry to perform the necessary dental services my child may need. I also authorize the dentists and staff of Center For Pediatric Dentistry to release any information including the diagnosis and records of treatment or examination rendered to my child during the period of such care to third party payers and/or health practitioners. I authorize the use of radiographs and photographs for the purpose of teaching and scientific publications. I request that my insurance company pay directly to the dentist. I agree to remain on the premises while my child is being treated. I understand that my insurance carrier may pay less than the actual bill for services; therefore, I agree to be responsible for payment of all services rendered on my child's behalf. I also agree that any fees incurred on this account for finance charges, missed appointments, collection actions or delayed payment by myself or the insurance company will be my responsibility.