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At the conclusion of the Consent Video please acknowledge that you have viewed
the information presented and you hereby acknowledge that major treatment
considerations and the potential risks of orthodontic treatment have been
presented to me in the video. |
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I have the following questions and/or comments as listed below: |
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I,
(one giving consent name here) hereby consent to the taking of diagnostic records, including x-rays before,
and following orthodontic treatment, and to provide orthodontic treatment for |
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I hereby authorize Paul L. Ouellette, DDS, MS, ABO to provide other health care
providers with information regarding
othodontic care as deemed appropriate by the Orthodontist of Record. I understand that once released,
the Orthodontist(s) has no responsibility for any further release by the
individual receiving this information. |
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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, education, or publication
consultations, research, education or publication in professional journals. |
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Type your email address 2X to complete your consent(s): |
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