Download ACKNOWLEDGEMENT I hereby acknowledge that I have received a

ACKNOWLEDGEMENT
I hereby acknowledge that I have received a copy, read, and understand the contents in the INFORMED CONSENT booklet. I
also understand that there may be other problems that occur less frequently than those presented, and that actual res ults may
differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned orthodontist(s) and have
been given the opportunity to ask any questions. I have been given the opportunity to make a choice about my treatment. I hereby
consent to the treatment proposed and authorize the orthodontist(s) indicated below to provide the treatment. I also authorize the
orthodontist(s) to provide my health care information to my other health care providers. I understand that m y treatment fee
covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical professionals i s not
included in the fee for my orthodontic treatment. I further understand that no guarantees or warranties have been given as to any
result since orthodontic treatment, by its nature, is health care, and many uncontrollable variables are involved.
CONSENT TO UNDERGO
Orthodontic Treatment
I hereby consent to the making of diagnostic records (including photographs, models and x-rays) before, during and after
orthodontic treatment. I hereby consent to the orthodontist(s) and staff (where appropriate) for providing the prescribed
orthodontic treatment. I also consent to continued authorized treatment if a change in treatment plan becomes necessary and/or
verbal agreement or consent is given for an alternate appliance, therapy method, re-treatment during the retention phase, or
referral for adjunctive treatment by a dentist, dental specialist or physician/therapist.
Acknowledgement of Accorde Orthodontists and Staff
I understand that while treatment is provided and directed by the patient’s primary orthodontist, a different orthodontist may
occasionally be present for treatment procedures and/or treatment directive. I authorize Dr. Mark Dale, Dr. Paul Hobday, Dr. Andrew
Helmich, the dental assisting staff (where appropriate), and rarely a substitute orthodontist or dentist, to provide treatment as needed
for the patient’s orthodontic care. I also understand that dental assistants will complete orthodontic procedures as directed, under
different levels of supervision, by the orthodontist(s) (as allowable by law).
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
I hereby authorize the above doctor(s) to provide other health care providers with information regarding the above individual’s
orthodontic care as deemed appropriate. I understand that once released, the above doctor(s) and staff has(have) no responsibility
for any further release by the individual receiving this information.
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Orthodontist
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Patient Name
__________________________________
Parent/Guardian Name
X_____________________________
Signature of Patient/Parent/Guardian
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Date
X
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Witness
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________
Date
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*Throughout the informed consent document, the words (or alternate forms) you, your child, or patient may also include the parent
or guardian when a minor or dependent is referenced.
CONSENT TO USE OF RECORDS
I hereby give my permission for the use of orthodontic records, including photographs made in the process of examination,
treatment, and retention for purposes of professional consultation, research education or publication in professional journals.
X__________________________
Signature of Patient/Parent/Guardian
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Date