Please bring the patient's dental insurance card(s) or a copy of the front and back of the dental insurance card(s) with you to the exam appointment.
Your answers to the following questions will be helpful in selecting the safest and most effective means of providing your dental care. All information will be kept completely confidential.
Because growth can be an important factor in orthodontic treatment planning, your answers to the following questions are needed to aid in our selection of treatment alternatives:
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained. I also acknowledge that I have received or have been give the opportunity to receive a copy of Casey Sayre Orthodontics Notice of Privacy Practices. By signing below I am giving acknowledgment that I have received or have had the opportunity to receive the Notice of our Privacy Practices.