ORTHODONTICS CONSENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

Step 1 of 2

Please read and initial the work to be done below, then read and sign the section at the bottom of the form.

PLEASE SELECT FROM THE DROPDOWN MENU
ROTATE YOUR PHONE TO ENTER FULLSCREEN
ASK DENTIST / RECEPTIONIST / DENTAL ASSISTANT
Please ask only receptionist, dental assistant or dentist to sign this consent form

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