Child Patient Form

GUARDIAN ONE

GUARDIAN TWO

INSURANCE INFORMATION

Do you have dental insurance?

Yes

HEALTH HISTORY

Has your child visited an orthodontist before?

Yes

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims.

Privacy Notice

I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by my insurance. I have also received a copy of this office's Notice of Privacy Practices:

Thanks for submitting!