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CHILD PATIENT FORM

WELCOME TO OUR PRACTICE
PATIENT INFORMATION
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MEDICAL HISTORY
DENTAL HISTORY

SIGNATURE OF RESPONSIBLE PARTY

CONSENT TO ORTHODONTIC RECORDS

I hereby grant authority to the team at Samra Orthodontics to take orthodontic records which consist of a panoramic radiograph, cephalometric radiograph, digital study models, and intraoral/extraoral pictures. Records are needed for the orthodontist to accurately provide a diagnosis and treatment recommendations. I understand that more detailed information will follow for specific procedures prior to treatment being rendered.

****Please notify our team if you suspect you might be pregnant prior to taking radiographs****

INSURANCE ASSIGNMENT OF BENEFITS

I hereby assign Samra Orthodontics all dental benefits to which I am entitled. I hereby authorize and direct my insurance carriers to issue payments directly to Samra Orthodontics for dental services rendered to myself or my dependent regardless of my insurance benefits. Samra Orthodontics will provide an estimate of insurance coverage upon request. I understand that Samra Orthodontics is not responsible for inaccurate estimates. Payments of claims are not guaranteed by any insurance and are based on eligibility and policy coverage at the time a claim is submitted. I understand that I am responsible for any amount not covered by insurance and I agree to pay any balance amount, in a timely manner.

Parent/Guardian Signature: