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Dr. Ashley Starnes
Dr. Jason Bongiovi
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Assignment/Release: I, the undersigned, assign directly to The Whole Tooth 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 Whole Tooth 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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ONLY IF SIGNING FOR A MINOR
Minor/Child Consent: I, being the parent or guardian of the patient listed above do hereby request and authorize the dental staff of The Whole Tooth 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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