Items marked with asterisk (*) must be completed.
Please answer any of the following which apply to you, and add any relevant comments
Please answer any of the following which apply to you.
I authorize release of any information regarding treatment to my dentist and/ or insurance company.Acknowledge by initialing Type a label* I authorize SuperSmile Orthodontics to bill insurance and accept payment for services rendered.Acknowledge by initialing Type a label* I certify that the above information is correct and accurate to the best of my knowledge. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in completing this form. I will notify the office of any changes regarding this form