I grant authority to Nathan P. Tenney, D.M.D. to perform dental and surgical procedures and treatments, including the administration of medicines and local anesthetics that are deemed necessary and advisable for this patient. Patient and/or legal guardian/parent will be informed before any treatment is performed. I authorize the release of any information necessary to expedite insurance claims, I understand that I am ultimately responsible for ANY and ALL charges, regardless of insurance coverage. I hereby certify the above to be true and correct to the best of my knowledge.