To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child ever have a change in health. By signing below, I am authorizing Dr. Christensen's office to bill my insurance for services rendered as a courtesy on my behalf. I am also acknowledging that it is exclusively my choice to undergo any dental procedure in this office and therefore, the full responsibility for all charges associated with any services rendered in this office is mine alone. Should my insurance fail to pay their contracted portion of any procedure in a timely manner (60 days), responsibility for the unpaid balance falls to me and it is my responsibility to follow up with my insurance company thereafter.