IF PATIENT IS 18 YEARS OF AGE & UNDER COMPLETE THE FOLLOWING
I, the undersigned, having insurance benefits and assign directly to Dr. Robert Pham all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electric.
I, being the parent/guardian of the child do hereby request and authorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, whether or not I am present at the actual appointment when treatment is rendered.
I, acknowledge that payment is due at the time of treatment, unless other arrangements are made. I agree that parent/guardian are responsible for all fees/services rendered for treatment of a minor/child. I accept full financial responsibility for all the charges not covered by insurance.
The above information is accurate and complete to the best of my knowledge and is only for the use in my treatment, billing and processing of insurance for benefits for which I am entitled. I will not hold my dentist or any member of the staff responsible for any errors or omissions that I may have made in the completion of this form
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