Orthodontistsofthenorthshore

I understand that the information that I have given today is correct to the best of my knowledge, that it is held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services that my child may need.

Signature of Parent or Guardian:

Date:

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.

Signature of Parent or Guardian:

Date:

If this office accepts my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co- payment and deductibles that my insurance does not cover. I hereby authorize payment of the group insurance benefits directly to this office.

Signature of Parent or Guardian:

Date:

The Parent or Guardian who accompanies the child is responsible for payment. Our office is HIPAA compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

WELCOME TO THE ORTHODONTIST

TELL US ABOUT YOUR CHILD

WHO IS ACCOMPANYING YOUR CHILD TODAY?

PARENTAL INFORMATION

PERSON RESPONSIBLE FOR THE ACCOUNT

ORTHODONTIC INSURANCE • PRIMARY

ORTHODONTIC INSURANCE • SECONDARY

WHAT WOULD YOU LIKE ORTHODONTICS TO ACCOMPLISH?

HAS YOUR CHILD EVER HAD ANY OF THE FOLLOWING MEDICAL PROBLEMS?

HAS YOUR CHILD EVER EXPERIENCED ANY OF THE FOLLOWING?

EMERGENCY CONTACT: RELATIVE OR FRIEND