I authorize release to my dental benefits plan administrator and the CDA, information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to Aurora Gateway Dental and also the use of my signature on all insurance submissions. I hereby assign my benefits, payable from claims submitted electronically, to Aurora Gateway Dental and authorize payment directly to them. This authorization shall continue in effect until the undersigned revokes the same.

I certify that I have provided an accurate and complete medical and dental history and have not omitted any information. I have had the opportunity to ask questions and have received answers regarding any concerns. I authorize the Aurora Gateway Dental team to perform and provide treatment as required. I also understand that the premises are under CCTV monitoring and I consent to this. I authorize the team to contact my physician regarding any relevant medical conditions.

I consent to the collection, use, and disclosure of this personal information for myself, or as the guardian of the patient in this form and accept all policies mentioned above.