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.