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.
PIease note that no data transmission over the internet can't be guaranteed to be 100% secure. As a resuIt, we cannot guarantee the security of any information you transmit to us over the internet, and you do so at your own risk. If you wouId prefer to contact us by teIephone to compIete this screening questionnaire, pIease caII: 604 892 5969