Orthodontic Treatment Consent Form

Patient Information

Patient Name Date of Birth Email Phone Number

Consent for Treatment

I hereby authorize Dr. and staff to perform orthodontic treatment. I acknowledge that the nature and purpose of the procedures, potential risks, and alternatives have been explained to me.

Medical History

Relevant medical or dental information

Comments or Questions

If you have any questions or concerns, please note them below

Signatures

Patient / Legal Guardian Signature Date