Please bring this completed form to your Initial Orthodontic Exam Appointment.
We look forward to meeting you!
The information I have provided is correct to the best of my knowledge. I understand it is my responsibility to inform
Hatala Orthodontics of any changes to this information. I authorize the dental staff of Hatala Orthodontics to perform any
dental services during diagnosis and treatment with my informed consent.
This Office reserves the right to verify credit status of potential patients and/or parents of patients 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.