I understand that I am responsible for payment of services rendered and also responsible for paying any copayments and deductibles that my insurance does not cover. In the event of a default on agreed upon payment arrangements, I am responsible for reasonable collection costs.
I have truthfully answered all of the above questions and agree to inform Kind Orthodontics of any changes in my medical or dental history. In addition, I authorize Dr. Emerald Nguyen or Dr. Nga Hoang to perform a complete orthodontic evaluation.