Payment is due in full at the time of treatment
unless prior arrangements have been approved.
If this office accepts 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 (otherwise payable to me) directly to this office. I understand that I am responsible For all costs of orthodontic treatment. I hereby authorize release of any information, including the diagnosis and records at treatment or examination rendered, to my insurance company.