This form is to acknowledge that I First Name Last Name, hereby authorize the following individuals to have access to all information relevant to the patient of record's treatment as outlined below. I understand that giving this authorization allows the below person(s) to receive information, while I am still responsible for this account. I understand that I have the right to retract this consent at any time by providing Brettin Orthodontics a written notice. By granting this access, I am acknowledging that I am a responsible party of the patient of record listed above and have the legal right to give access to financial and/or treatment information the below individual(s).