I GIVE PERMISSION TO DISCLOSE PROTECTED HEALTH INFORMATION TO THE FOLLOWING PERSONS:
Has patient ever been diagnosed or treated for:
If the patient will be in orthodontic therapy, We require a general dental visit every six months.
I promise all information given is accurate and true. I authorize release of any information relating to this claim and necessary for processing. I authorize payment directly to Henn Orthodontics of the 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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