Consent for Orthodontic Treatment

Name: Profile Orthodontics
Telephone: 08 9300 9975

Fields marked * are required.

Patient Acknowledgement

I have read and I understand the information outlined in the Orthodontic Fact Sheet.

I have read, I understand and I accept the Treatment Agreement outlining the fee for treatment and the Payment Plan.

I understand that digital photographic and radiographic images have been taken and I authorise that they may be sent to my referring Dental Practitioner or other Specialists as required during treatment.

Respectful Behaviour

We're committed to providing a safe and respectful environment for everyone at our practice. We ask that all patients and their families treat our team with courtesy at all times. Aggressive, abusive, or disrespectful behaviour is not acceptable. If this occurs, we may need to end care and refer you to another provider.

I agree

Patient Authorisation

I authorise the use of digital photographic images and radiographs by the Orthodontist for educational purposes.

Yes

I authorise the display of my own or my child’s own digital photographic image within the practice to celebrate a wonderful new smile at the end of treatment.

Yes

I hereby authorise the orthodontist to proceed with the agreed treatment program and any otherrelated procedures deemed necessary, including additionalradiographic images, for the welfare and treatment of:

Patient's Name *

Patient's E-mail *

Name of person completing this form *

Relationship to Patient *

Today's Date *

Please sign here *: