I HEREBY give Dr

By Brittany Anderson,2014-09-26 23:30
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I HEREBY give Dr


    I HEREBY give _______________________the absolute right and permission to use my photographs/slides for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.

    Signature___________________________________ Date_______________________


    1. I hearby authorize doctor or designated staff to take x-rays, study models,

    photographs, and other diagnostic aids deemed appropriate by doctor to make

    a thorough diagnosis of (name of patient) ______________________’ s dental


    2. Upon such diagnosis, I authorize doctor to perform all recommended

    treatment mutually agreed upon by me and to employ such assistance as

    required to provide proper care.

    3. I agree to the use of anesthetics, sedatives and other medication as necessary.

    I fully understand that using anesthetic agents embodies certain risks. I

    understand that I can ask for a complete recital of any possible complications.

    4. I agree to be responsible for payment of all services rendered on my behalf or

    my dependents. I understand that payment is due at the time of service unless

    other arrangements have been made. In the event payments are not received

    by agreed upon dates, I understand that a 1 ?% late charge (18% APR) may

    be added to my account. If required, I also understand a check of my credit

    history may be made.

Patient’s signature ________________________________ Date _________________

    Witness ________________________________________ Date __________________

Parent/Responsible Party’s Signature ________________________________________

    Relationship to Patient ____________________________________________________

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