I understand that the information I have given is correct to the best of my knowledge, that it will be held in the strictest confidence, and that it is my responsibility to inform this office of any changes in the patient's medical status. I authorize the orthodontic staff to perform the necessary orthodontic services the patient may need.
This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credits reporting services. I understanding that I am responsible for payment of services rendered and also responsible for paying any insurance co-payment and deductibles that my insurance does not cover. I hereby authorize the orthodontist to release all information necessary to secure the payment or benefits.