I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my child’s medical status.

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

I authorize the dental staff to perform any necessary dental services my child may need.

If this office accepts insurance, I understand that I am responsible for payments of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover.

I have read the above questions and understand them. I will not hold my orthodonist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.

The Parent or Guardian who accompanies this child is responsible for payment. Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and ADA.