RELEASE AND WAIVER
I have read the above questions and understand them. I will not hold my orthodontist or any member of his/her staff responsible for any errors or omissions that I have made in the completion of this form. I will notify my orthodontist of any changes in my medical or dental health history.
I authorize release of any information regarding my orthodontic treatment to my dental insurance company. As a condition of treatment by this office, I understand financial arrangements must be made in advance. I authorize and understand a complete examination to develop an orthodontic treatment plan sometimes includes x-rays, photographs, and study models. I have read the above conditions and agree to their content.