responsible party (if patient is a minor)
orthodontic insurance information
medical information (please answer any that apply)
the above information is true to the best of my knowledge. i have read and understand the above questions. i understand that my information will be held in the strictest of confidence. i will not hold dr. christopher or any member of his staff responsible for any errors or omissions that i have made in completion of this form. if there are any changes later to the history record or medical/dental status, i will so inform walla walla orthodontics.
notice of privacy practiced
**you may refuse to sign this acknowledgement**
i have been informed of my orthodontic provider’s notice of privacy practices. i have been given the right to receive a full and complete copy of this office’s notice of privacy practices.