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.
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.