Consent For Office Participation

Patient First Name:
Middle Initial:
Patient Last Name:

Dr. Romick and his staff are committed to truly getting to know their patients. Patients are known by their names, their interests, hobbies and involvement in their communities. We also realize that orthodontic treatment is a significant event in the lives of our patients. We enjoy recognizing these special moments by including names of our patients on a bulletin board in our office waiting area. In addition, we also love being updated on the accomplishments and achievements of our patients. The front office staff reviews local news in order to discover positive and exciting articles regarding our patients. We will also celebrate your in-office achievements (patient of the month, contest winners, when you finish treatment, etc.)!

The following release authorizes the office of Romick Orthodontics to post the name and relevant information regarding the patient on our waiting room bulletin board, website, social media, and office "Wall of Fame".


Responsible Party Signature:
Date:
Refuse To Participate Signature:
Date: