Patient

PARENT/GUARDIAN

Dentist

General Information

FINANCIAL RESPONSIBILITY

We are sorry that we cannot accept divorce decrees as assignment of responsibility for your child’s orthodontic bills.
The custodial parent is financially responsible for the services and should seek any reimbursement from the other parent.

DENTAL INSURANCE

MEDICAL INSURANCE

PHYSICIAN

Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation.
For the following questions, please mark Yes, No, Or Don’t Know/Understand (Dk/U).

DENTAL HISTORY

Now or in the past, has your child had:

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

Have the parents or siblings ever had any of the following health problems? If so, please explain.

Our office is HIPPA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health. I authorize the orthodontic staff to perform the necessary dental services that I may need during diagnosis and treatment with my informed consent.

AUTHORIZATION

This office reserves the right to verify the credit status of potential patients and/or parents prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the orthodontist to release all information necessary to secure the payment of benefits. I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submissions, whether manual or electronic.

I authorize any photographs, x-rays, or study models to be used for displays at scientific meetings, presentations, and publications of scientific nature or for study group purposes (to further the art and science of orthodontics) or for the use in our office and for advertising/marketing purposes.