Responsible Party Information
Patient Health History
I acknowledge that I have completed this from to the best of my ability and the information is true. I will not hold my orthodontist or any member of the staff responsible for omissions or errors that I may have made during the completion of this form. If there are any changes to this medical record, I understand that I must provide the information to the office in a reasonable time frame (within 30 calendar days)
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.