I have the legal right to preauthorize the office of Dr. John Siegmund / Dr. Jon Anderson and their personnel to deliver routine dental treatment and services to my child. Routine Dental care and interventions may include, but are not limited to: dental evaluation, exam, dental x-rays, fluoride cleaning of teeth and orthodontic services.
Identify any specific limitations on the kinds of dental services for which this authorization is given. (If none, state “none.”) Parental contact information for questions regarding treatment of the child:
Powered by Top Rated Local®