Orthodontic Consent Forms Test | Goldfields Family Dental

Orthodontic Consent Form

Patient Name(Required)

First Name Surname

Date of Birth(Required)

Email(Required)

Phone(Required)

Please review the orthodontic information sheets below before your appointment. If you have any questions, these can be discussed with our dental team. Once reviewed, please complete and sign this acknowledgement form.

Aligners Information
Braces Care Information
CBJ Information

I, the patient and/or the parent or legal guardian, confirm that I have read the orthodontic information sheets linked above.

Patient/Guardian Name(Required)

Patient/Guardian Signature(Required)

Date(Required)

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Orthodontic Consent Form

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