I have been given the opportunity to ask any questions regarding the nature and purpose of orthodontic
treatment and have received answers to my satisfaction. I have been given the alternative of seeking care with an orthodontic
specialist. I do voluntarily assume any and all possible risks, including risk of substantial harm, if any, which may be associated with
any phase of this treatment in hopes of obtaining the desired potential results, which may or may not be achieved. No guarantees or
promises have been made to me concerning any results from treatment. The fee(s) for these services have been explained to me and I
accept them as satisfactory. By signing this form, I accept all terms and conditions expressed within it and freely give my consent to
authorize Dr.______________________________ and any and all associates necessary in rendering services that he/she deems necessary or
advisable for this subject orthodontic treatment.