INFORMED CONSENT AND TREATMENT CONFIRMATION
Patient First Name:
Last Name:
Acknowledgement of informed Consent
I have read the brochure, "Your Orthodontic Treatment", which outlines orthodontic treatment procedures and potential risks. I hereby acknowledge that the major treatment considerations and potential hazards and problems may include, but are not limited to, those described in the brochure.
Hulme Orthodontics and/or their Treatment Coordinator has discussed with me the orthodontic treatment planned for
presenting information used in the decision making process. I have had an opportunity to discuss the proposed treatment and ask additional questions regarding the information on this form.
I also understand that, like other healing arts, the practice of orthodontics is not an exact science. Therefore, results cannot be guaranteed.
Signature:
Date:
Witness:
Date:
Consent to undergo orthodontic treatment
I hereby consent to Hulme Orthodontics providing treatment for:
Signature:
Date: