Murdock Orthodontics

Specialist in ORTHODONTICS and Dentofacial Orthopedics
5420 North Bend Road, Cincinnati, Ohio 45247

Dental Insurance Only

Primary Dental Insurance

Secondary Dental Insurance

I authorize release of any information relating to any orthodontic claim filed by Murdock Orthodontics. I understand that I am responsible for all fees not covered by the above named insurance company(s). I authorize payments directly to Donald R. Murdock, DMD, MS, LLC.

Does the patient now or at any previous time:

Has the patient been diagnosed or exposed to any of the following conditions?

I give consent for Dr. Murdock to contact the health care professionals listed above, if necessary, to insure that any of the aforementioned symptoms or conditions will not interfere with their orthodontic treatment. I also give consent for my/my child's records to be transmitted via mail, electronic facsimile, email or computer projection to communicate with or educate other health care providers. I authorize Dr. Murdock to obtain a credit report if deemed necessary.