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PATIENT INFORMATION
PARENT/GUARDIAN INFORMATION
DENTAL INSURANCE INFORMATION
Primary Insurance
Secondary Insurance (if applicable)
Medical History
DENTAL HISTORY
RELEASE AND WAIVER

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 child’s medical or dental health.

Parent/Guardian Signature:

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

Parent/Guardian Signature: