Office Consents and HIPAA Acknowledgement

First Name:

Middle Initial:

Last Name:

Consent to Photographs

I hereby give permission to GLK Orthodontics and their qualified staff to take diagnostic photographs to explain orthodontic treatment options.

Consent to Diagnostic Records

I hereby give permission to GLK Orthodontics and their qualified staff to take diagnostic records to plan orthodontic treatment. These records can include radiographs and study models.

Consent to Use Records

I hereby give my permission for the use of orthodontic records (made in the process of examination, treatment, and retention) for purposes of professional consultations, board examinations, research, education, or publication in professional journals.

Consent to Use Photo

I hereby authorize GLK Orthodontics to use my photo or my child’s photo on their website, on an office presentation and/or for any promotional material (i.e. brochure).

Insurance Payment Authorization

I hereby authorize payments to GLK Orthodontics for the group insurance benefits otherwise payable to me for services provided to my child or myself by GLK Orthodontics. I am aware that if any insurance check is sent to me, I am responsible for forwarding these payments to GLK Orthodontics.

Acknowledgement of Receipt of Notice of Privacy Practices

I have received a copy to read (available via this link) of this office’s Notice of Privacy Practices.

Patient/Legal Guardian type your full name to sign your consent and acknowledgement:

For a Legal Guardian, please indicate your relationship to the patient (if applicable):