Signature Orthodontics

Dental Insurance

Primary Insurance Company Name

Member ID

Orthodontic Coverage

Yes

Unsure

Insured's Name

Insured's DOB

Photo of Insurance Card - Front & Back Please!

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Secondary Insurance Company

Secondary Insurance - Member ID

Secondary Insurance - Group Number

Secondary Insurance - Orthodontic Coverage

Yes

Unsure

Secondary Insurance - Insured's Name

Secondary Insurance - Insured's DOB

Secondary Insurance - Photo of Insurance Card (front & back please!)

Choose file

Acknowledgement of Full Medical Disclosure

Our team is here to help and ensure our patients have as comfortable, pleasant, and safe of an experience as possible. In order to provide the best care, it is very important for us to have a full picture of the following for the patient undergoing treatment:

- medical history
- past and current habits
- behavioral issues
- physical limitations
- anxiety (dental, the unknown, etc.)
- sensitivity (light, vibration, sensory, etc.)
- trigger points

Knowing these details will help us find the best way to manage your child’s / your care and make the most appropriate recommendations. In the event that heightened sensitivity, increased anxiety, and intolerance of appliances in the mouth occurs we may recommend to pause or discontinue treatment once treatment has begun. Although that is never our intention to do so, your child’s/your dental health and safety is our top priority.

By checking this box it means you have disclosed the patient’s medical history and additional pertinent information to the best of your knowledge.

Confirmed

Informed Consent

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION OR INFORMATION NOT DISCLOSED.

I consent to any and all diagnostic procedures and orthodontic treatment provided by the doctors, assistants, or other personnel. I release any information concerning my child's health care, advice and treatment to another dentist fo evaluating and administering treatment. I authorize payment of any dental benefits to Signature Orthodontics for services rendered. I certify that I have legal authority under applicable law to act on behalf of the patient identified above.

Signature

Relationship to Patient

Today's Date

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