PARENT INFORMATION (IF MINOR PATIENT)
PRIMARY DENTAL INSURANCE
SECONDARY DENTAL INSURANCE
Go Clear Orthodontics
259 Textile Way ° Suite 103 ° Fort Mill, SC 29715
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 confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
I understand that I am responsible for payment of services rendered. I understand that I am responsible for paying any costs that my insurance will not cover. I also understand that insurance pays over my treatment time, and may not pay in full up front. If I change or lose my insurance for any reason during my treatment, I will be responsible for any charges remaining on the account.