ASSIGNMENT OF CLAIM Permission is granted to download, print or otherwise copy this form for your personal use. I authorize and direct my attorney, ____________________________ to pay directly to Dr. __________________, such sums as may be due and owing to him/her for dental treatment rendered to me and to hold such sums from any settlement, judgment or recovery resulting from my claim now pending against I fully understand that I am directly and completely responsible to Dr. _______________________ for all dental fees incurred for services rendered to me and that this assignment is made solely for Dr._____________________ protection and in consideration of Dr.____________________ rendering treatment to me while awaiting payment therefor. I further understand and agree that such obligation to payDr.___________________ is not contingent on any settlement, judgment or recovery which I may eventually obtain. Patient Witness Date: To Consent Library