I hereby give Rad orthodontics and/or members of her staff permission to release information concerning me or my child's dental and/or orthodontic
health to the family physician, dentist or any other dental specialist as is deemed necessary from time to time. Such information includes x-rays and
other diagnostic records which pertain to the initial condition, diagnosis, proposed treatment or treatment in progress.
I, the undersigned, certify that I have read and understand the above medical and dental information, have reviewed it, and find it accurate. If there
are any later changes to the patient’s clinical history, I recognize that it is my responsibility to inform this office. I also give my permission for clinical