Orthodontic Insurance Information

Orthodontic Insurance Information | Wazio Orthodontics

beautiful smiles for a lifetime

Please fill out the form below and we will contact you as soon as possible!

Patient Name:

Date of Birth

Patient School (if student):

City:

Primary Policy Holder Information

Name:

ID# or SS:

Relationship to Patient:

Martial Status:

Employer:

Dental Insurance Company:

Group #:

Insurance Effective Date:

City:

State:

Zip:

Insurance Company Telephone No.:

I authorize release of information relating to this claim.

Electronic Signature

Date:

I hearby authorize payment directly to Wazio Orthodontics the group insurance benefits otherwise payable to me.

Electronic Signature

Date:

950 W. Wilson Street

Batavia, IL 60510 • 630.879.7774

403 S. 3rd Street

St. Charles, IL 60174 • (630) 584-6050

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