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Your answers to the following questions are extremely important for an accurate diagnosis. Thank you for your patience in answering the following questions:
NOTE: We make every attempt to schedule appointments for convenience, but orthodontics appointments may infringe on your school/ work schedule.
I understand that records are stored electronically and that an electronic copy shall be considered an original for all purposes.
By law, we are required to provide you with our Notice of Practice. Please sign below acknowledging your receipt of this information. This shall also serve as consent to use and/or disclose your protected health information to carry out treatment, payment activities, and health care operations. If you should have any questions regarding this Notice and consent, you may contact: Paige Orthodontics at 281-358-6580