If different from patient information, please complete
If different from previous information, please complete
I consent to the taking of photographs and X-rays before, during, and after treatment, and to the use of same by the doctor in scientific papers or demonstrations. I understand taht the information that I have given 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 in my medical status. I authorize the Orthodontist to share this patient's treatment information with collaborating dentist and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the insurance company for billing purposes only.