Book my free consultation

Record Taking Consent

I hereby authorize the licensed dental providers or designated staff to take x-rays, study models, photographs, and other diagnostic aids, henceforth referred to as “records,” deemed appropriate by the dental provider to make a thorough diagnosis. Upon such diagnosis, I authorize the licensed dental provider or designated staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

I hereby authorize the dentist or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis Upon such diagnosis, I authorize the dentist or designated staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

I hereby authorize CVSTOM Co. to provide other health care providers with information about this my orthodontic care as deemed appropriate.

By signing up to this service I certify to have read, understood, and consent to the above.