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· 2018. 3. 13. · I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Signature Date I have read the above

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Page 1: · 2018. 3. 13. · I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Signature Date I have read the above

Page 2: · 2018. 3. 13. · I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Signature Date I have read the above

Page 3: · 2018. 3. 13. · I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Signature Date I have read the above

Page 4: · 2018. 3. 13. · I authorize release of any information regarding my orthodontic treatment to my dental and/or medical insurance company. Signature Date I have read the above

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