I understand orthodontic treatment: straightening or repositioning of teeth includes certain risks and potential unsuccessful results. Even though great care and diligence will be used in treatment, no promises or guarantees for desired results or outcome can be made or expected.
I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. I acknowledge that I have had full opportunity to read and consider the contents of this consent forma nd yoru notice of privacy practices.
Michael J. Cook DMD, MS
1030 E. 11400 S. Suite 4 Sandy, Utah 84094