I acknowledge that this information is correct and will be held in the strictest confidence. I authorize Jefferson Dental Clinics to contact me regarding promotions and services. I authorize Jefferson Dental Clinics to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. Payment is due in full at the time of treatment unless prior arrangements have been approved. I understand that I am responsible for paying any copayment and deductibles that my insurance soes not cover. I hereby authorize payment directly to Jeferson Dental Clinics of the group insurance benefits otherwise payable to me. I hereby authorize release of any information, including the diagnosis and records of treatment or examination rendered to my insurance company.