Health History Mini Update Form

Pediatric & Adolescent Dentistry and Orthodontics

Please correct the errors described below.

HEALTH HISTORY

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. By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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