I, the undersigned, do hereby request and give my permission to Michael Berger, D.M.D. and Berger Orthodontics to provide other health care
providers and insurance companies any and all information with respect to my dental care. Such records may
include medical care and treatment, illness or injury, dental history, medical history, consultation,
prescriptions, xrays, models and copies of all dental and medical records.
I, the undersigned, do hereby relinquish any and all rights to photographs, portraits, prints, or other
photographic reproductions captured with still, motion picture, video, digital or other cameras for use by
Michael Berger, D.M.D. and Berger Orthodontics. Unless images are used to communicate with another care provider, no
names, birthdates or identifiable information will be linked to any image.