I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status.
I hereby authorize the release of the patient’s information pertaining to medical treatment necessary to process any insurance claims. I further authorize the application for benefits on the patient’s behalf for covered services and payment of any benefits to the office. I understand that I am responsible for my amount not covered by insurance.
I understand that appropriate, credit bureau reports may be obtained.
I hereby consent to Laidlaw Orthodontics performing radiology services as ordered and recommended for treatment. I hereby authorize to provide my radiologic studies and related health care information to my dentist or referred professional care provider.
I hereby consent to treatment recommended by Dr. Andrea Laidlaw here at Laidlaw Orthodontics or treatment that is referred by Dr. Andrea Laidlaw to be conducted by other professional care provider.