1)I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis.
2)I agree to be responsible for payment of all services on my behalf or my dependents, including any unpaid insuarance benefits I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a $30.00 late charge may be added to my account.
3)I hereby give Lisa Grant Orthodontics the absolute right and permission to use my photographs / slides for educational or promotional purposes via print or social media. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.
I have a clear understanding of the treatment recommended by the doctor and agree to move forward with the recommended treatment