I understand that the information that I have provided is correct to the best of my knowledge, that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes. I hereby authorize the release of any information related to insurance claims. I consent to the examination by the doctor and I authorize payment of any insurance benefits to the office. I hereby give Kingry Orthodontics permission to confirm appointments using the phone number(s) provided, including leaving messages. I understand that, where appropriate, credit bureau reports may be obtained.