At todays visit the patient is scheduled for a: "Growth and Development appointment" this visit to see the Doctor is complimentary. We scheduled a patient to the development to prepare for the need of Orthodontic treatment. In the event that the doctor may need to have a diagnostic radiograph taken maybe a fee accessed prior to taking this image. We ask that you update our insurance/medical records on a regular basis. Please take a moment to update our patient information document. If you have any questions, please see one of our receptionist. Please beware that we are working in the ERA of COVID-19 and that we have made several new office policy changes in regards to visitors and selective procedure types. Thank you

Primary Orthodontic Insurance:
Secondary Orthodontic Insurance: (Assign to Subscriber)

Sgnature of patient (Parent/Guardian if patient is under age 18)