Parent or Guardian Initials Requested - I hereby understand and agree to the terms outlined on page 1 of this Informed Consent.
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Patient or Parent/Guardian Initials
Parent or Guardian Initials Requested - I hereby understand and agree to the terms outlined on page 2 of this Informed Consent.
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Patient or Parent/Guardian Initials
Consent to use of Records
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Yes, I hereby give my permission for the use of orthodontic records, including photographs made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals.
No, I decline.
Acknowledgment of Document
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Yes, I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form.
No, I decline.
Patient's First and Last Name
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First Name
Last Name
Email address
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Today's Date
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Month
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Day
Year
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Signature Required (if not signed we will have you do a paper copy if office)
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Parent or Guardian signature required if under 18.
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