Consent Form

Patient First Name:

Last Name:

Birthdate:

CONSENT TO UNDERGO ORTHODONTIC DIAGNOSTIC RECORDS

I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment.

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

I hereby authorize Mitchell, Bartlett & Bell Orthodontics to provide other health care providers with information regarding the above individual's orthodontic care as deemed appropriate. I understand that once released, the doctors and staff of Mithcell, Bartlett & Bell Orthodontics have no responsibility for any further release by the individual receiving this information.

CONSENT TO USE RECORDS

I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment and retention for purposes of professional consultations, research or education.

Signature: