Bock Orthodontics believes in the importance of a happy, healthy smile.  It is our priority to ensure you achieve and maintain optimal oral health.  Please fill out the form below completely so that we may better care for you.

Dental Insurance Information

Emergency Information

Medical History

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and that it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services that my child may need during diagnosis and treatment with my informed consent.

This office reserves the right to verify the credit status of potential patients and/or parents prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services. If this office accepts insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize the dentist to release all information necessary to secure the payment of benefits. And I assign directly to the doctor all insurance benefits otherwise payable to me. I further authorize the use of this signature on all my insurance submissions, whether manual or electronic.

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