Health History Mini Update Form

Pediatric & Adolescent Dentistry and Orthodontics

Please correct the errors described below.


In the event insurance payments are not received, I understand that I am ultimately responsible for my balance. I understand that all responsibility for payments for dental services provided in the office to my child are due and payable at the time services are rendered unless other arrangements have been made. In the event that payments are not received by the agreed dates, I understand that 1½ % finance charge (18%) Apr may be added to my account.

I hereby authorize payment directly to the named doctor of the Group Insurance Benefits otherwise payable to me.

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