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ORTHODONTIC SPECIALISTS Professional Corporation I agree to have orthodontic records taken on my child, ______________________ Which consists of photos, cephalometrical x-ray and a set of study models. If a panoramic x-ray is not supplied by the dentist, there may be an additional charge. Should I decide not to continue with treatment I will be responsible for the cost of these records and consultation if applicable. I also authorize Orthodontic Specialists, P.C., to get a credit analysis on me if they feel necessary. Name _______________________ Date______________ SS#_______________________________