RELEASE OF MEDICAL INFORMATION FOR PURPOSES OF CONSULTATION
Patient Name: .
| , by my signature below consent to the release of my child's medical information for the purposes of obtaining a consultation and hereby consent to the following:
- I understand that orthodontic practice is not an exact science and that there may exist various interpretations
of, approaches to, and means for correcting a given orthodontic problem.
- It is natural and expected, that at certain times, health care providers, including orthodontists, will consult with one another about certain diagnostic aspects and treatment alternatives concerning one of their patients.
- I understand that my dentist may consult with other health care providers concerning certain aspects of my
treatment and I encourage him/her to do so for my benefit whenever the need arises.
- I understand that if my dentist undertakes to consult with other health care providers concerning my diagnosis
and/or treatment, my medical records may be evaluated by other health care practitioners. Therefore, l fully consent to the release of any medical information contained therein for this purpose.
- If my dentist consults with other doctors about my diagnosis or treatment, it is my understanding that:
- Any recommendations made to my dentist may or may not be followed, as my dentist sees fit.
- I may or may not consult with any of the consultants,
- I may or may not ever meet any ofthe consultants,
- I do not have an expectation of having a doctor-patient professional relationship with any consultant whom I do
- I do not expect to be billed by any consultant with whom I do not meet.
- If my dentist does consult with other health care providers for my benefit:
- I expect him/her to use his/her best professional judgement in evaluating the consultant’s recommendations,
- I expect him/her to use whatever information or input he/she receives in my best interest
- I expect the ultimate diagnostic and treatment recommendations to rest with my dentist and not with the
- All decisions regarding accepting or rejecting treatment recommendations made by my dentist rests with me.
- If English is not my primary language, I have had the opportunity to have this interpreted for me and I fully
understand the words and concepts expressed herein.
- I have had the benefit and the opportunity to ask and have answered any questions pertaining to this release.