I grant permission for the following people to receive Treatment information regarding my / my child's treatment.
If no, please provide the following information:
Dental/Orthodontic insurance is a benefit purchased by/for you to help cover your treatment fees. We cannot be responsible for the type of policy that has been purchased. As a courtesy, we will complete and file a claim on your behalf; however you are responsible for the entire fee. If the information you supply is incomplete or inaccurate, you will be responsible for full payment to our office as well as filing claims to your insurance carrier.