Star Smiles Ortho & Pediatric Dentistry

MEDICAL HISTORY

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services.



Star Smiles

148 E Lake St, Suite C- Bloomingdale, IL 60108
Office (630)980-8800
Fax (630)477-0340
www.starsmilesorthopedo.com
Info@starsmilesorthopedo.com

Authorization and release:

To the best of my knowledge, the above information is complete and correct. I understand that is my responsibility to inform my doctor If I, or my minor child, ever have a change in health.

I certify that I. and/or my dependent (s), have insurance coverage with and assign directly to Dr. Raquel M. Jham all insurance benefits, if any, otherwise payable to me form services rendered. I understand that I am financially responsible for all changes, whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named dentist may see my health care information and may disclose such information to the above named insurance, company (ies) and their agents for the purpose of obtaining payment for services and determining insurances benefits payable for related services. This consent will end when the current treatment plan is completed or one year from the date signed below.


Star Smiles

148 E Lake St, Suite C- Bloomingdale, IL 60108
Office (630)980-8800
Fax (630)477-0340
www.starsmilesorthopedo.com
Info@starsmilesorthopedo.com