I understand the information that I have given is correct to the best of my knowledge and that it will be held in the
strictest of confidence. It is my responsibility to inform this office of any changes in my/my child’s medical status. I
also authorize the orthodontic staff to perform the necessary orthodontic services I/my child may need.
I have also read, understand and have been offered a copy of the HIPAA consent form.
The parent/guardian/patient present is responsible for payment at the time of service unless prior arrangements have been approved