I, the undersigned, do hereby request and give my permission to Dr. Rebecca Bockow, DDS, MS and Inspired
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
Rebecca Bockow, DDS, MS, and Inspired Orthodontics. Unless images are used to communicate with another care provider,
no names, birthdates or identifiable information will be linked to any image.