I hereby certify, on behalf of (myself) (my child), and all those who may now or in the future have any interest in the care and treatment of (myself) (my child), that I have, on my own volition and as my voluntary act, requested removal of my orthodontic appliances by Dr.

I hereby certify, on behalf of (myself) (my child), and all those who may now or in the future have any interest in the care and treatment of (myself) (my child), that I have, on my own volition and as my voluntary act, requested removal of my orthodontic appliances by Dr.

In consideration of, among other things, said Doctor’s agreement to remove my appliances at my request and such removal, the sufficiency of which is hereby acknowledged, I do hereby, on behalf of (myself) (my child), and all those who may now or in the future have any interest in the care and treatment of (myself) (my child), now and forever release and discharge said Doctor, his/her agents, employees, professional corporation, insurers and assigns from any loss, costs, damages or expenses arising out of the removal of my appliances as aforesaid. I understand that this is a full waiver and release of any and all claims (I)

or anyone claiming through or on behalf of (me) (my child) may now have or may acquire in the future arising out of the removal of (my) (my child’s) appliances as aforesaid by said Doctor, his/her agents or employees. I further understand that, by executing this Release and Waiver and said Doctor’s agreement to remove my appliances at my request and such removal, (I)

and anyone claiming through or on behalf of (me) (my child) will be forever foreclosed from any claim for damages arising out of or related to the removal of said appliances as aforesaid.
br> This Release and Waiver is the entire agreement between the undersigned parties. The undersigned, in executing this Release and Waiver, acknowledges that the consideration recited herein is the consideration for the full and final release and waiver contained herein, and that no other understandings or agreements, representations or promises, verbal or otherwise, have been relied upon by the undersigned in executing this Release and Waiver.

*If the patient is a minor, a parent or guardian must sign and the capacity of the signer should be indicated. For example, “Jane Doe, parent/guardian of John Doe, a minor.”