If yes, please provide details below:
I grant permission for Mountain Orthodontics to share pertinent information with other medical, dental, and insurance professionals as it relates to the patient’s orthodontic treatment and overall dental care.
I authorize release of information from my insurance company as it relates to the patient’s dental/orthodontic claims, benefits, pre-determinations and coverage.
To the best of my knowledge, I have answered all questions accurately and truthfully. I understand that providing incorrect information may be dangerous to the patient’s health. I also agree to inform the Orthodontist and/or staff member of any changes in the patient’s medical status or other pertinent information.