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
Date
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Please provide us with a valid email address for newsletters, appointment reminders, and bad weather closings.
E-mail:
Initial:
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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 #
The Art of Orthodontics
705 S. Custer Rd., Ste 130
Allen, TX 7503
Office: 469-393-0333