Patient Information

Responsible Party If Applicable

Health History

Dental History

I understand that the information I have given is correct to the best of my knowledge and it is my responsibility to inform the office of any changes in my health status. I understand that by signing this form I am accepting all responsibility for full payment of services rendered regardless of insurance coverage.

As a courtesy to our patients, we will file your insurance claim with the insurance company listed above for treatments your child receives. However, in the event the insurance company, for any reason, does not pay, the balance will become your responsibility, and will be billed directly to you. You understand that this contract is with Noe Valley Smiles and Braces and yourself, and you are responsible for all charges on the account.

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