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: