I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in the medical status of the patient named herein. Additionally, I hereby consent to an initial examination of the patient named herein.
I will not hold the orthodontist or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. I understand that I am responsible for the payment of services rendered and for paying and co-payment and deductibles that my insurance does not cover.