Patient Information (Child)


Patient Information/Health History (Child)

    Patient Information

  • Father's Information

  • Mother's Information

  • Primary Dental Insurance

  • Secondary Dental Insurance

  • Legal

  • I hereby authorize payment directly to Brandi Hodge, D.D.S, P.A. for all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges, whether or not paid by insurance, and for all services rendered on my behalf or my dependents.

    I authorize the above doctor and/or any provider or supplier of services in this office to release the information required to secure the payment of benefits. I authorize use of this signature on all insurance submissions.

    I have had full opportunity to read and consider the contents of the Notice of Privacy Practice for Hodge Family Dentistry. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

 

Verification