I authorize Cook Orthodontics, P.C. to submit insurance claims on my behalf. My signature also serves as my consent for insurance benefits to be assigned to Cook Orthodontics, P.C. I understand that I am financially responsible for all charges whether or not paid by insurance.
I have read and understand the above questions. I will not hold Dr. Cook or any member of his staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status I will so inform this practice.
I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize Cook Orthodontics, P.C. and the dental staff to perform necessary dental/orthodontic services my child may need.