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Dr. Jason Bongiovi
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Assignment/Release: I, the undersigned, assign directly to Pediatric Dentistry of Forsyth 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 Pediatric Dentistry of Forsyth to release all information necessary to secure payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
 
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Minor/Child Consent: I, being the parent or guardian of the patient listed above do hereby request and authorize the dental staff of Pediatric Dentistry of Forsyth to perform necessary dental services for my child, including but not limited to radiographs, local anesthetics, nitrous oxide analgesia and other acceptable methods to accomplish these services, whether or not I am present at the actual appointment when the treatment is rendered.
 
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