Authorization and Release Agreement 

I certify that I am the authorized party executing this form. I have read and understood the information provided in this form to the best of my knowledge and have truthfully answered all questions. I understand that providing incorrect information can be dangerous to my health and wellbeing. I authorize the dental care provider to release any information such as patient examinations, diagnosis, and treatment rendered during the period of such orthodontic care to third-party payers and/or health practitioners. If it is deemed appropriate, I understand that credit bureau reports may be obtained.

By providing an electronic signature using an electronic device, you are signing the Authorization and Release Agreement electronically on the date of the submission of this form and agree that your electronic signature and form submittal is the legal equivalent of your manually written and dated signature, confirming your acknowledgement and acceptance of the Authorization and Release Agreement's terms and conditions.