Please answer the below screening questions based on how your child acts in general during the past month.
I give permission and authorize Orchin + Orchin Specialists in Orthodontics doctors and staff to take diagnostic records for the purpose of planning orthodontic treatment. I allow the use of orthodontic records for professional consultations, research, education, or publication in professional journals. I understand Orchin + Orchin Specialists in Orthodontics uses recordings for security and training purposes. I authorize Orchin + Orchin Specialists in Orthodontics doctors to share patient treatment information when collaborating with dentists and other healthcare professionals as appropriate and to bill insurance for procedures performed, or to inquire about estimated treatment. I authorize payment to Orchin + Orchin Specialists in Orthodontics for the group insurance benefit otherwise payable to me for any services rendered. I, the above-named responsible party, understand the above information is necessary to provide the above named patient with orthodontic care, I have answered all questions to the best of my knowledge and I will notify this dental care facility of any and all changes regarding health, health care providers, or medications. I consent to the performing of dental procedures agreed to be necessary or advisable.Signature*Date*
Thank you so much for your time! We look forward to seeing you soon! :)
Dr. Andrew M. Orchin + Dr. Jill M. Orchin + The Orchin Team