Insurance & Medication List Form

Patient's Name

Patient's Number

Date of Birth

Insurance Carrier Name

Phone

Address

Subscriber Name

Phone

Address

Subscriber Social Security Number

Subscriber id number (if not ssn)

Subscriber’s Birth date

Employer's Name

Group No.

I hereby authorize the release of any information relating to the orthodontic treatment of

in order to bill my insurance for such services.

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

Signature of patient or parent if minor

I hereby authorize payment directly to Pitts Orthodontics of the group insurance benefits otherwise payable to me

Signature of insurance subscriber

MEDICATION LIST

Please complete the list below for any medications you are currently taking including aspirin, vitamins, herbal supplements:

Add Medication

Please list any medications you are allergic to:

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