IMPORTANT NOTE: After you have completed this form, you MUST scroll to the bottom of the signature page and click the space (marked with an X) to sign your name digitally, and then submit your signature. This form will not be considered complete unless this crucial final step is completed!

Patient Information

Parent / Guardian Information

Dentist Information

General Information

Financial Responsibility

Dental Insurance

Medical Insurance

Physician

RELEASE AND WAIVER

I authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.

I have read the above questions and understand them. I will not hold my orthodontist 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.