Wazio Orthodontics

Orthodontic Insurance Information

Patient Name: Date of Birth:

Patient School (if student): City:

Primary Policy Holder Information

Name: ID# or SS: Date of Birth:

Relationship to Patient: Martial Status Employer Dental Insurance Company Group # Insurance. Effective Date Insurance Co. Address City State Zip Insurace Company Telephone No.
I authorize release of information relating to this claim. Electronic Signature Date:

I hearby authorize payment directly to Wazio Orthodontics the group insurance benefits otherwise payable to me. Electronic Signature Date: