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.
CONSENT FOR TREATMENT
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 ____________________________________________________