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  • WELCOME TO CC BRACES

    ADULT’S INFORMATION
  • Employment

  • Spouse

  • Insurance Information

    Please allow us to make a copy of your insurance card
  • Name of Policy Holder
  • Emergency Information

  • Name of nearest relative not living with you
  • Medical Information

  • General Dentist

  • Family Physician

  • Dental/Medical History

  • Women Only

  • Diseases / Allergies

  • Entry NA if not applicable
  • Type NA if not applicable
  • Enter NA if not applicable
  • I authorize release of any information regarding my child’s orthodontic treatment to my dental and or medical insurance company.
    I have read the above questions and understand them. I will not hold my orthodontist or any member of his staff responsible for any errors or omissions that I have made in the completion of this form.
    I will notify my orthodontist of any changes in my child’s medical or dental health
  • HIPAA Policy

  • PRIVACY POLICY


    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
    DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
  • Authorization to Release Patient Record Information

    I, hereby authorize CC Braces to disclose facial and/or dental photographs, photographs, and video of the following patient as approved below:
  • Financial Disclosure: I understand that the practice is not receiving compensation from anyone for use of the patient's photo.

    Refusal to Sign: I understand that refusal to sign part or all of this Authorization will in no way affect the patient's treatment.

    Revocation: I understand that I may revoke this authorization at any time by sending a written notice to the practice. All photos will be removed at the time the revocation is received.