I authorize Local Orthodontics to contact the individual(s) listed above to convey information as listed above regarding the ‘patient’ in the event that I am unable to be reached by Local Orthodontics.
I understand that I may revoke/cancel this authorization by notifying Local Orthodontics, in writing, of my intent to revoke authorization, or change the name(s) of those listed to whom the information is to be released.
Please note that if the patient is under the age of 18, a Legal Guardian must either be present during the Initial Consultation, or must have this page filled out with the name of the individual(s) bringing the patient to the Exam.