In the event of an emergency, is there someone we should contact?
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
If Lee Orthodontics accepts my dental insurance, I understand that I am responsible for any co-payments/deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits (otherwise payable to me) directly to this office.
Lee Orthodontics is HIPAA Compliant and is committed to meeting or exceeding the standard of infection control mandated by OSHA, the CDC, and ADA.