Dental Forms New Patient FormMedical Dental History Form for Adult PatientsMedical Dental History Form for Patients Under Age 18Confidential Questionnaire FormNew Patient Form Please prove you are human by selecting the Truck. Medical Dental History Form for Adult Patients PATIENTDate MM slash DD slash YYYY Name First Last I prefer to be called Birth date MM slash DD slash YYYY Sex Male Female Social Insurance Number Marital Status Single Married Separated Divorced Widowed Home address City, State, Zip code Home PhoneCell PhoneWork PhoneEmail Occupation Employer CLOSEST RELATIVESpouse or closest relative’s name(s) Relationship to patient Address (if different than patient address) Home PhoneCell PhoneWork PhoneDENTISTPatient’s Dentist Address, City, State Last seen Reason Next Appointment Other dentists/dental specialists now being seen: City, State Reason PHYSICIANPatient’s Physician City, State Last seen Reason Next Appointment Most recent physical exam Other physicians/health care providers being seen now:Name City, State Reason Name City, State Reason GENERAL INFORMATIONWhat concerns you about your teeth? Who suggested that you might need orthodontic treatment? Why did you select our office? Have you had any previous orthodontic treatment? Please describe Have any other family members been treated in this office? Please name them. Do you think that any of your work or leisure activities affect your teeth or jaws? Please explain. FINANCIAL RESPONSIBILITYWho is financially responsible for this account? Address City, State, Zip Home PhoneCell PhoneWork PhoneSocial Security Number Employer Who will be responsible for bringing the patient to orthodontic appointments? DENTAL INSURANCEPrimary policy holder’s full name Birth Date MM slash DD slash YYYY Social Security Number Relationship to patient Address and phone (if not listed above) Employer Address Insurance company Group Number ID Number Does this policy have orthodontic benefits? Yes No Don't know Seondary policy holder’s full name Birth Date MM slash DD slash YYYY Social Security Number Relationship to patient Address and phone (if not listed above) Employer Address Insurance company Group Number ID Number Does this policy have orthodontic benefits? Yes No Don't know MEDICAL INSURANCEPolicy holder’s full name Insurance company Your answers are for office records only, and are confidential. A thorough medial history is essential to a complete orthodontic evaluation. For the following questions mark yes, no, or don't know/understand (dk/u).MEDICAL HISTORYNow or in the past, have you had Birth defects or hereditary problems? Yes No Don't know Bone fractures, or major injuries? Yes No Don't know Any injuries to face, head, neck? Yes No Don't know Arthritis or joint problems? Yes No Don't know Endocrine or thyroid problems? Yes No Don't know Diabetes or low sugar? Yes No Don't know Kidney problems? Yes No Don't know Cancer, tumor, radiation treatment or chemotherapy? Yes No Don't know Stomach ulcer, hyperacidity, acid reflux? Yes No Don't know Immune system problems? Yes No Don't know History of osteoporosis? Yes No Don't know Gonorrhea, syphilis, herpes, sexually transmitted diseases? Yes No Don't know AIDS or HIV positive? Yes No Don't know Hepatitis, jaundice or other liver problem? Yes No Don't know Polio, mononucleosis, tuberculosis, pneumonia? Yes No Don't know Seizures, fainting spells, neurologic problem? Yes No Don't know Mental health disturbance or depression? Yes No Don't know Vision, hearing, or speech problems? Yes No Don't know History of eating disorder (anorexia, bulimia)? Yes No Don't know High or low blood pressure? Yes No Don't know Excessive bleeding or bruising, anemia? Yes No Don't know Chest pain, shortness of breath, tire easily, swollen ankles? Yes No Don't know Heart defects, heart murmur, rheumatic heart disease? Yes No Don't know Angina, arteriosclerosis, stroke or heart attack? Yes No Don't know Skin disorder (other than common acne)? Yes No Don't know Do you eat a well-balanced diet? Yes No Don't know Frequent headaches or migraines? Yes No Don't know Frequent ear infections, colds, throat infections? Yes No Don't know Asthma, sinus problems, hayfever? Yes No Don't know Tonsil r adenoid condition? Yes No Don't know Do you frequently breathe through your mouth? Yes No Don't know DENTAL HISTORYNow or in the past, have you had Permanent or extra (supernumerary) teeth removed? Yes No Don't know Supernumerary (extra) or congenitally missing teeth? Yes No Don't know Chipped or injured primary or permanent teeth? Yes No Don't know Any sensitive or sore teeth? Yes No Don't know Bleeding gums, bad taste or mouth odor? Yes No Don't know Jaw fractures, cysts, infections? Yes No Don't know Any teeth treated with root canals or pulpotomies? Yes No Don't know "Gum boils,” frequent canker sores or cold sores? Yes No Don't know History of speech problems or speech therapy? Yes No Don't know Difficulty breathing through nose? Yes No Don't know Food impaction between the teeth? Yes No Don't know Mouth breathing habit or snoring at night? Yes No Don't know History of speech problems? Yes No Don't know Frequent oral habits (sucking finger, chewing pen, etc.)? Yes No Don't know Teeth causing irritation to lip, cheek or gums? Yes No Don't know Abnormal swallowing (tongue thrust)? Yes No Don't know Tooth grinding or clenching? Yes No Don't know Clicking, locking in jaw joints? Yes No Don't know Soreness in jaw muscles or face muscles? Yes No Don't know Ringing in ears, difficulty in chewing or opening jaw? Yes No Don't know Have you ever been treated for “TMJ” or “TMD” problems? Yes No Don't know Any broken or missing fillings? Yes No Don't know Any serious trouble associate with previous dental treatment? Yes No Don't know Have you ever been diagnosed with gum disease or pyorrhea? Yes No Don't know Have you ever had an orthodontic consultation or treatment before now? Yes No Don't know Have you had allergies or reactions to any of the following:Local anesthetics (novocaine, lidocaine, xylocaine) Yes No Don't know Latex (gloves, balloons) Yes No Don't know Aspirin Yes No Don't know Ibuprofen (Motrin, Advil) Yes No Don't know Penicillin Yes No Don't know Other antibiotics Yes No Don't know Metals (jewelry, clothing snaps) Yes No Don't know Acrylics Yes No Don't know Plant pollens Yes No Don't know Animals Yes No Don't know Foods Yes No Don't know Other substances Yes No Don't know PATIENT HEALTH INFORMATIONList any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that you take.MedicationTaken for Have you ever taken any medications to strengthen your bones? Please describe. Do you take antibiotic pre-medication before any dental procedures? Yes No Do you or have you ever had a substance abuse problem? Do you chew or smoke tobacco? Have you noticed any changes in your face or jaws? Any other physical problems? How often do you brush? How often do you floss? Women: Are you pregnant? Yes No Are you trying to become pregnant? Yes No FAMILY MEDICAL HISTORYHave your parents or siblings ever had any of the following health problems? If so, please explain.Bleeding disorders Diabetes Arthritis Severe allergies Unusual dental problems Jaw size imbalance Other family medical conditions? RELEASE AND WAIVERI authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company.Signature Date MM slash DD slash YYYY I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health.Signature Date MM slash DD slash YYYY MEDICAL HISTORY UPDATES OR CHANGESChanges Patient Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Changes Patient Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Changes Patient Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Captcha Medical Dental History Form for Patients Under Age 18 PatientDate MM slash DD slash YYYY Name First Last Prefers to be called Hobbies, Activities Birthdate MM slash DD slash YYYY Sex Male Female Social Insurance Number School Grade Email Home Address City, State, Zip Code Home PhoneCell PhonePARENT/GUARDIANCustodial Parent(s) Name(s) Patient Lives With (check all that apply) Mother Father Stepmother Stepfather Grandparents Other Father's Full Name Occupation Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneMother's Full Name Occupation Email Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneCell PhoneWork PhoneDENTISTPatient's Dentist Address, City, State, ZIP Last Seen Reason Next Appointment Other Dentists Now Being Seen City, State Reason GENERAL INFORMATIONWhat concerns you have about your child’s teeth? What concerns your child have about his/her teeth? How does your child feel about orthodontic treatment? Who suggested that your child might need orthodontic treatment? Why did you select our office? Describe any previous orthodontic treatment or consultations. Does your child play a musical instrument? Brother/Sister Name and Age Had orthodontic treatment? If yes, where? Brother/Sister Name and Age Had orthodontic treatment? If yes, where? Brother/Sister Name and Age Had orthodontic treatment? If yes, where? Brother/Sister Name and Age Had orthodontic treatment? If yes, where? Have any other family members been treated in this office? Please name them. FINANCIAL RESPONSIBILITYWho is financially responsible for this account? Address (if different from page 1) City, State Home PhoneCell PhoneEmail Social Security Number Employer Who will be responsible for bringing the patient to orthodontic appointments? DENTAL INSURANCEPrimary policy holder’s full name Birth Date MM slash DD slash YYYY Social Security Number Relationship to Patient Address and phone (if not listed above) Employer Insurance Company Group Number ID Number Does this policy have orthodontic benefits? Yes No Don't Know Secondary policy holder’s full name Birth Date MM slash DD slash YYYY Social Security Number Relationship to Patient Address and phone (if not listed above) Employer Insurance Company Group Number ID Number Does this policy have orthodontic benefits? Yes No Don't Know MEDICAL INSURANCEPolicy holder’s full name (Medical Insurance) Insurance company PHYSICIANPatient’s Physician City, State Last seen Reason Next appointment Most recent physical exam Name of other physicians/health care providers being seen now: City, State Reason Name of other physicians/health care providers being seen now: City, State Reason Your answers are for office records only, and are confidential. A thorough medical history is essential to a complete orthodontic evaluation. For the following questions, please mark yes, no, or don’t know/understand (dk/u).MEDICAL HISTORYNow or in the past, has your child had Birth defects or hereditary problems? Yes No Don't know Bone fractures, or major injuries? Yes No Don't know Any injuries to face, head, neck? Yes No Don't know Arthritis or joint problems? Yes No Don't know Cancer, tumor, radiation treatment or chemotherapy? Yes No Don't know Endocrine or thyroid problems? Yes No Don't know Diabetes or low sugar? No Yes Don't know Kidney problems? Yes No Don't know Immune system problems? Yes No Don't know History of osteoporosis? Yes No Don't know Gonorrhea, syphilis, herpes, sexually transmitted diseases? Yes No Don't know AIDS or HIV positive? Yes No Don't know Hepatitis, jaundice or other liver problems? Yes No Don't know Polio, mononucleosis, tuberculosis, pneumonia? Yes No Don't know Seizures, fainting spells, neurologic problem? Yes No Don't know Mental health disturbance or depression? Yes No Don't know History of eating disorder (anorexia, bulimia)? Yes No Don't know Frequent headaches or migraines? Yes No Don't know High or low blood pressure? Yes No Don't know Excessive bleeding or bruising tendency, anemia? Yes No Don't know Chest pain, shortness of breath, tire easily, swollen ankles? Yes No Don't know Heart defects, heart murmur, rheumatic heart disease? Yes No Don't know Angina, arteriosclerosis, stroke or heart attack? Yes No Don't know Skin disorder (other than common acne)? Yes No Don't know Does your child eat a well-balanced diet? Yes No Don't know Vision, hearing, or speech problems? Yes No Don't know Frequent ear infections, colds, throat infections? Yes No Don't know Asthma, sinus problems, hayfever? Yes No Don't know Tonsil or adenoid condition? Yes No Don't know Does your child frequently breathe through his/her mouth? Yes No Don't know Has your child ever taken intravenous bisphosphonates such as Zometa (zolendromic acid), Aredia (pamidronate) or Didronel (etidronate) for bone disorders or cancer? Yes No Don't know Has your child ever taken oral bisphosphonates such as Fosamax (alendronate), Actonel (ridendronate), Boniva (ibandronate), Skelid (tiludronate) or Didronel (etidronate) for bone disorders? Yes No Don't know Has your child had allergies or reactions to Local anesthetics (novocaine, lidocaine, xylocaine) Yes No Don't know Allergies to Latex (gloves, balloons) Yes No Don't know Allergies to Aspirin Yes No Don't know Ibuprofen (Motrin, Advil) Yes No Don't know Allergies to Penicillin Yes No Don't know Other antibiotics Yes No Don't know Metals (jewelry, clothing snaps) Yes No Don't know Acrylics Yes No Dont know Plant pollens Yes No Don't know Animals Yes No Don't know Foods Yes No Don't know Other substances Yes No Don't know DENTAL HISTORYNow or in the past, has the patient had Erupting teeth very early or very late? Yes No Don't know Primary (baby) teeth removed that were not loose? Yes No Don't know Permanent or extra (supernumerary) teeth removed? Yes No Don't know Supernumerary (extra) or congenitally missing teeth? Yes No Don't know Chipped or injured primary or permanent teeth? Yes No Don't know Any sensitive or sore teeth? Yes No Don't know Any lost or broken fillings? Yes No Don't know Jaw fractures, cysts, infections? Yes No Don't know Any teeth treated with root canals or pulpotomies? Yes No Don't know Frequent canker sores or cold sores? Yes No Don't know History of speech problems or speech therapy? Yes No Don't know Difficulty breathing through nose? Yes No Don't know Mouth breathing habit or snoring at night? Yes No Don't know History of speech problems? Yes No Don't know Frequent oral habits (sucking finger, chewing pen, etc.)? Yes No Don't know Teeth causing irritation to lip, cheek or gums? Yes No Don't know Tooth grinding or clenching? Yes No Don't know Clicking, locking in jaw joints? Yes No Don't know Soreness in jaw muscles or face muscles? Yes No Don't know Has your child been treated for “TMJ” or “TMD” problems? Yes No Don't know Any broken or missing fillings? Yes No Don't know Any serious trouble associated with previous dental treatment? Yes No Don't know Has your child ever been diagnosed with gum disease or pyorrhea? Yes No Don't know PATIENT HEALTH INFORMATIONDo you think that any of your child’s activities affect his/her face, teeth or jaws? How? List any medication, nutritional supplements, herbal medications or non-prescription medicines, including fluoride supplements that your child takes.MedicationTaken for Do you take antibiotic pre-medication before any dental procedures? Yes No Does the patient currently have (or ever had) a substance abuse problem? Does your child chew or smoke tobacco? Have you noticed any unusual changes in your child’s face or jaws? Any other physical problems? FAMILY MEDICAL HISTORYHave the parents or siblings ever had any of the following health problems? If so, please explain.Bleeding disorders Diabetes Arthritis Severe allergies Unusual dental problems Jaw size imbalance Other family medical conditions? How often does your child brush? Floss? RELEASE AND WAIVERI authorize release of any information regarding my child’s orthodontic treatment to my dental and/or medical insurance company.Parent/Guardian Signature Date MM slash DD slash YYYY I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my child’s medical or dental health.Parent/Guardian Signature Date MM slash DD slash YYYY MEDICAL HISTORY UPDATESChanges Parent/Guardian Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Changes Parent/Guardian Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Changes Parent/Guardian Signature Date MM slash DD slash YYYY Dental Staff Signature Date MM slash DD slash YYYY Captcha Confidential Questionnaire Form CONFIDENTIAL INFORMATION QUESTIONNAIREPatient's Legal NameLast Name* First Name* MI* Prefer to be called* Date of Birth* MM slash DD slash YYYY Sex*MaleFemaleHome Phone NumberCell Phone Number Patient's AddressStreet Apartment Number City State Zip Code Email Marital Status* Single Married Widowed Divorced Under Age 18 Patient's/Guardian's Employer Occupation Work AddressStreet Apartment Number City State Zip Code Work Phone NumberSpouse's NameLast name First name Middle Initial Spouse's employer Occupation Spouse's work addressStreet Apartment number City State Zip code Work Phone NumberOther family members that are patients here Who can we thank for referring you to our office? EMERGENCY CONTACT INFORMATIONPerson we may contact in case of an emergency (other than your family home)Name Relationship Home Phone NumberWork Phone NumberCellphone Number REQUEST FOR CONFIDENTIAL COMMUNICATIONAs my dental care provider, you may do the following with my permission:Contact me at home Yes No Contact me via cell phone Yes No Contact me at work Yes No Contact me via e-mail Yes No Leave messages on my home voicemail/answering machine Yes No Leave messages on my cell phone voicemail Yes No Leave messages on my work voicemail/answering machine Yes No INSURANCE AND FINANCIAL INFORMATIONInsurance coverage* Yes No Insurance company name Insurance address Insurance phoneSubscriber's Name Subscriber's Birthday Subscriber's SSN/ID Number Patient's relationship to subscriber Self Spouse Dependent Group/Program number Employer (if different from above) Employer's address Secondary Coverage Yes No Insurance company name Insurance address Insurance phoneSubscriber's Name Subscriber's Birthday Subscriber's SSN/ID Number Patient's relationship to subscriber Self Spouse Dependent Group/Program number Employer (if different from above) Employer's address CONFIRMATIONSDo you prefer a confirmation call* No, it is unnecessary Yes, it is a helpful reminder ASSIGNMENT & RELEASEI hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations and/or presentations.I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.SIGNATURE - Patient/Guardian* Date MM slash DD slash YYYY WITNESS SIGNATURE* Date MM slash DD slash YYYY Captcha
