Patient Consent Forms

Completion of these forms is required for all new patients.

They are combined into this 1 page so you can easily complete them online, with a computer or mobile device.  Your response will be submitted to us securely.

If you have any questions, please give us a call.


Step 1 of 2

Patient Consent for Photographs and/or Radiography

I hereby consent to and authorize Authentic Orthodontics and its employees to record by means of still photographs, radiography (x-ray) and/or video of the above named patient and to reproduce, exhibit or publish these works for the purposes set out herein.

  • For use by our office and any of your other health care providers for the purpose of diagnosis and documentation of treatment progress

I hereby waive any, and all claims which I may at any time have against Authentic Orthodontics or its employees, in any matter whatsoever relating to the said photographs.

I represent that I am the parent/person having lawful custody of the above named patient. I hereby consent to the foregoing on the patient’s behalf. I understand that I can withdraw my consent at any time and acknowledge that in order to do so, I must provide written notice to Authentic Orthodontics.

Clear Signature