DENTAL AND MEDICAL HISTORY (If yes, please fill in details)
RELEASE AND WAIVER,
I authorize release of any information regarding my orthodontic treatment to my dental insurance company.
I have read the above questions and understand them. I will not hold my orthodontist or any member of her staff responsible for any erros or omissions that I have made in the completion of this form. I will notify deRoode Orthodontics of any changes in my medical or dental health.