I hereby GRANT Dr. Cody Oldham permission to post/display a photograph/image of myself and/or my child(ren) in his office or on Oldham Orthodontics’ website and/or social media.
This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask our office staff.
I hereby acknowledge that I have reviewed a copy of this privacy notice. (PDF available on Patient Forms section of www.OldhamOrtho.com or at the front desk)
I hereby authorize Oldham Orthodontics to release my and/or my child's orthodontic records, including x-rays, to my and/or my child's general dentist and/or other dental specialist/health care provider as applicable.
I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the Orthodontist to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the Orthodontist to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only.