Adult New Patient Form



This information is accurate and true to the best of my knowledge. I understand that I am responsible to pay for services rendered. I further understand that if a payment becomes 30 days past due, a $5.00 late fee will be assessed. I hereby authorize the release of medical information, if necessary, and payments from the above mentioned insurance company to go directly to Dr. Paul Serrano/Serrano & Kyger Family Orthodontics. I also understand I am responsible for any balance that my insurance company does not pay. I am aware that when appropriate, this office may request a credit history profile.


Be sure to bring the printed form with you on your first visit.