Medical Release
I hereby authorize The Art of Orthodontics to release medical or incidental information that may be necessary for medical care or to process medical insurance claims for which payment is assigned to the provider.
Patient/Parent or Guardian Name Printed
Patient/Parent or Guardian Name Signature
Date
Please provide us with a valid email address for newsletters, appointment reminders, and bad weather closings.
E-mail:
Initial:
I authorize that The Art of Orthodontics may speak with the following family member (s) regarding any medical and billing information.
Name of family member
Relationship to Patient
Phone #
Name of family member
Relationship to Patient
Phone #