Informed
Consent

for the Orthodontic Patient

Risks and Limitations of Orthodontic Treatment

Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should seriously consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.

Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention, interception and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.


An orthodontist is a dental specialist who has completed at least two additional years of graduate training in orthodontics at an accredited program after graduation from dental school.

  • Results of Treatment

    Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satis-fied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoid-ing loose or broken appliances, and following the orthodontist’s instructions carefully.

  • Length of Treatment

    The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extend-ed beyond the original estimate, additional fees may be assessed.

  • Discomfort

    The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Non-prescription pain medication can be used during this adjustment period.

  • Relapse

    Completed orthodontic treatment does not guaran-tee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treat-ment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that con-tinue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situa-tions may require non-removable retainers or other dental appliances made by your family dentist

  • Extractions

    Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the procedure.

  • Orthognathic Surgery

    Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you should discuss with your oral and/or maxillofa-cial surgeon prior to beginning orthodontic treatment.

  • Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment!
  • Decalcification and Dental Caries

    Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/ or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened beverages or foods.

  • Root Resorption

    The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth through-out life with severely shortened roots. If resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the com-pletion of orthodontic treatment.

  • Nerve Damage

    A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.

  • Periodontal Disease

    Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitor your periodon-tal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.

  • Injury From Orthodontic Appliances

    Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliance can be inhaled or swallowed or could cause other damage to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when ortho dontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

  • Headgears

    Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes. In the event of injury or especially an eye injury, however minor, immediate medical help should be sought. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.

  • Temporomandibular (Jaw) Joint Dysfunction

    Problems may occur in the jaw joints, i.e., temporo-mandibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without ortho-dontic treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.

  • Impacted, Ankylosed, Unerupted Teeth

    Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the partic-ular circumstance and the overall importance of the involved tooth, and may require extraction, surgical exposure, surgical transplantation or prosthetic replacement.

  • Occlusal Adjustment

    You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby “flattening” surfaces in order to reduce the possibility of a relapse.

  • Non-Ideal Results

    Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal result (for example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges or periodontal therapy, may be indicated. You are encouraged to ask your orthodontist and family dentist about adjunctive care.

  • Third Molars

    As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or ortho-dontist should monitor them in order to determine when and if the third molars need to be removed.

  • Allergies

    Occasionally, patients can be allergic to some of the component materials of their orthodontic appli-ances. This may require a change in treatment plan or discontinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.

  • General Health Problems

    General health problems such as bone, blood or endocrine disorders, and many prescription and non-prescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that you inform your ortho dontist of any changes in your general health status.

  • Use of Tobacco Products

    Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treat-ment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

  • Temporary Anchorage Devices

    Your treatment may include the use of a temporary anchorage device(s) (i.e. metal screw or plate attached to the bone.) There are specific risks associated with them.

    It is possible that the screw(s) could become loose which would require its/their removal and possibly relocation or replacement with a larger screw. The screw and related material may be accidentally swallowed. If the device cannot be stabilized for an adequate length of time, an alternate treatment plan may be necessary.

    It is possible that the tissue around the device could become inflamed or infected, or the soft tissue could grow over the device, which could also require its removal, surgical excision of the tissue and/or the use of antibiotics or antimicrobial rinses.

    It is possible that the screws could break (i.e. upon insertion or removal.) If this occurs, the broken piece may be left in your mouth or may be surgically removed. This may require referral to another den-tal specialist.

    When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary.

    Local anesthetic may be used when these devices are inserted or removed, which also has risks. Please advise the doctor placing the device if you have had any difficulties with dental anesthetics in the past.

    If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.

  • ACKNOWLEDGEMENT

    I hereby acknowledge that I have read and fully understand the treatment considera-tions and risks presented in this form.
    I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results.
    I also acknowledge that I have discussed this form with the undersigned orthodon-tist(s) and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the orthodontist(s) indicated below to provide the treatment. I also authorize the orthodontist(s) to provide my health care information to my other health care providers. I understand that my treat-ment fee covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical pro-fessionals is not included in the fee for my orthodontic treatment.

  • CONSENT TO UNDERGO ORTHODONTIC TREATMENT

    I hereby consent to the making of diagnos-tic records, including x-rays, before, during and following orthodontic treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.

  • AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

    I hereby authorize the above doctor(s) to provide other health care providers with information regarding the above individual’s orthodontic care as deemed appropriate.
    I understand that once released, the above doctor(s) and staff has(have) no responsibili-ty for any further release by the individual receiving this information.

  • CONSENT TO USE OF RECORDS

    I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, educa-tion, or publication in professional journals.

  • I have the legal authority to sign this on behalf of

  • Notes

    PATIENT'S COPY

BRENT FREY,DDS

Specialist in Orthodontics &
Dentofacial Orthopedics

BROKEN BRACKET POLICY

Ok folks, this one is simple. If the brackets are not attached to the teeth, the braces can't do their job! Granted, it is difficult to complete treatment without having breakages. However, patients who break multiple brackets at a time or who break a bracket or two in between each appointment put themselves at serious risk for delayed progress and compromised results.

As your orthodontic provider, my team and I take great pride in practicing solid technique. In order to deliver consistent results, orthodontic technique must be combined with patient compliance. When this combination exists, orthodontics is efficient and rewarding. The following policy is designed to give you the best chance of successful treatment.

Young patients, if you break a bracket, tell your parents. Parents and adult patients, call the office to report breakages. We would like to be prepared for the additional time required to repair the brackets.

After the third broken bracket, fees may be assessed for broken brackets ($35/each), molar tubes ($50/ each). Fees will be assessed at the discretion of Dr. Frey.

The purpose of this policy is not to punish anyone, nor is it designed for profit. The goal is to promote responsible and aware patients. When patients understand the importance of taking care of their orthodontic appliances, it greatly improves the chances of successful treatment. Dr. Frey and the Champion Smiles Team thanks you for your commitment!

Prince George's Metro Center ||| | 6525 Belcrest Road, Suite 290 | Hyattsville, MD 20782
North Oak Professinal Center | 3060 Mitchellville Road, Suite 108 | Bowie, MD 20716
301-249-4123 | info@smile-champs.com | www.smile-champs.com

BRENT FREY,DDS

Specialist in Orthodontics &
Dentofacial Orthopedics

APPOINTMENT SCHEDULING

Orthodontics is unlike any other dental treatment. Treatment is generally non-invasive and is delivered over a period of months to years. During active treatment, you will visit the office once every one or two months. Another unique aspect of orthodontic treatment is that clinical assistants are trained to perform a number of basic orthodontic procedures, such as placing and tying in wires. Routinely, you will notice that the assistants will start working on the patient, Dr. Frey will look closely at the patient and plan the next step, and the assistant will finish working on the patient. Thus, our office can be very busy at peak times. To ensure that the schedule runs smoothly, we take special care of when certain procedures are scheduled.

Seventy-five percent of each patient’s appointments are basic adjustments including placing new ties or wires. These appointments can require as few as five minutes of chair time. The busiest portion of our schedule is before and after work/school hours. These appointment times are highly coveted! Because you have to visit the office once every month or two during active treatment, we understand why you like to avoid having office visits conflict with your personal schedule on a regular basis. To accommodate our patients, we reserve peak times in the schedule for routine adjustment appointments. From 7am-9:30am and 2pm-5pm, we only schedule wire and tie changes.

Generally, orthodontic patients will have no more than five appointments that last longer than 30 minutes. The new patient exam, records, consultation, placement of braces, removal of braces, and other special procedures require appointments that can take more than 30 minutes. Not only are the appointments longer, Dr. Frey may spend a lot of time working with patients for these procedures.

All of the more time consuming and clinically sensitive appointments are scheduled during mid to late morning. Initially, some patients may feel frustrated that they have to take off work or school for these longer appointments. By scheduling long appointments during off-peak times, it allows us to get you in and out of the office quickly during peak times when you have short appointments. Thus, for the majority of the treatment, you should be able to schedule appointments at times that do not conflict your personal schedule. Also, scheduling lengthy and clinically sensitive appointments during off peak hours gives us the time we need to focus on delivering precise, successful care.

Here are some things to remember. Emergency appointments can be scheduled during peak times. However, if the emergency involves breakage of orthodontic appliances, we will only do what is needed to make the patient comfortable during peak time. Because it takes extra time to repair broken appliances, we will have you come back at an off-peak time for the repair. If you know that something is broken, make sure you call so we can schedule accordingly. If you come in for a routine adjustment appointment and don’t call to report a broken bracket, we will make sure you are comfortable and schedule you during off peak hours for the repair.

When you or your child has a broken bracket and we ask you to come back for the repair, it may seem unfair. Keep in mind that if we schedule you for a ten-minute adjustment appointment and we spend an extra 20 minutes fixing something that has been broken, it will cause everyone else’s appointment’s to be delayed. Thus, if you value our ability to get you in and out of the office for the majority of your appointments, you must also understand why we can’t spend extra time on unscheduled repairs during peak times.

Prince George's Metro Center ||| | 6525 Belcrest Road, Suite 290 | Hyattsville, MD 20782
North Oak Professinal Center | 3060 Mitchellville Road, Suite 108 | Bowie, MD 20716
301-249-4123 | info@smile-champs.com | www.smile-champs.com

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

UNDERSTANDING YOUR HEALTH INFORMATION

Each time you visit our office, we make a record of your visit in order to manage the care you receive. We understand that the medical information that is recorded about you and your health is personal. The confidentiality and privacy of your health information is also protected under both state and federal law.
This Notice of Privacy Practices describes how this office may use and disclose your information and the rights that you have regarding your health information.

How We Will Use or Disclose Your Health Information

Treatment: We will use your health information for treatment. For example, information obtained by the orthodontist or other members of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your orthodontist will document in your record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observations, so the physician will know how you are responding to treatment. We will also provide your physician, or a subsequent healthcare provider, with copies of various reports that should assist him or her in treating you.

Payment: We will use your health information for payment. For example, a bill may be sent to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used. Health Care Operations: We will use your health information for our regular health care operations. For example, we may use information in your health record to assess the care and outcome in your case and others like it. This information will then be used in a continued effort to improve the quality and effectiveness of the services we provide.

Business Associates: We may enter into contracts with persons or entities known as business associates that provide services to or perform functions on our behalf. Examples include our accountants, consultants, and attorneys. We may disclose your health information to our business associates so they can perform the job we have asked them to do, once they have agreed in writing to safeguard your information.

Notification: We may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided to us, e.g., on an answering machine.

Communication with Family: We may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Appointment Reminders / Health Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other health benefits that may be of interest to you.

Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to coroners or medical examiners, to carry out their duties consistent with applicable law.

Organ Procurement Organizations: Consistent with applicable law, we may disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Research: We may disclose your health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also disclose your health information to people preparing to conduct a research project, so long as the health information is not removed from us. We may also use and disclose your health information to contact you about the possibility of enrolling in a research study.

Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of receiving such communications.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Workers’ Compensation: We may disclose health information to the extent authorized by and to the extent necessary, to comply with laws relating to workers’ compensation or other similar programs established by law.

Public Health Activities: As required by law, we may disclose your health information to public health, or legal authorities, charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities: We may disclose your health information to health oversight agencies for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, health information necessary for your health and the health and safety of other individuals.

Judicial and Administrative Proceedings: We may disclose your health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individual or a protective order are provided.

Law Enforcement Purposes / Serious Threat to Health or Safety: We may disclose your health information to enforcement officials for law enforcement purposes under certain circumstances and subject to certain conditions. We may also disclose your health information to prevent or lessen a serious and imminent threat to a person or the public (when the disclosure is made to someone we believe can prevent or lessen the threat) or to identify or apprehend an escapee or violent criminal. Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your health information to appropriate government authorities if there are allegations of abuse, neglect, or domestic violence.

Essential Government Functions: We may disclose your health information for certain essential government functions (e.g., military activity and for national security purposes). The following uses and disclosures will be made only with your authorization: (i) with limited exceptions, uses and disclosures of your health information for marketing purposes, including subsidized treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other uses and disclosures not described in this notice. You may revoke your authorization at any time in writing, except to the extent that we have taken action in reliance on the use or disclosure indicated in the authorization.

Your Health Information Rights

Although your health record is the physical property of this office, you have the following rights with respect to your health information:

  • You may request that we not use or disclose your health information for a particular reason related to treatment, payment, our general healthcare operations, and/or to a particular family member, other relatives or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, except as provided below.
  • If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your health plan. We ask that such requests be made in writing on a form provided by us. We are required to abide by such a request, except where we are required by law to make a disclosure. We are not required to inform other providers of such a request, so you should notify any other providers regarding such a request.
  • You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing, and submitted to the Privacy Officer. We will attempt to accommodate all reasonable requests.
  • You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by law. If we maintain your health information electronically in a designated record set, you may obtain an electronic copy of the information. If you request a copy (paper or electronic), we will charge you a reasonable, cost-based fee.
  • If you believe that any health information in your record is incorrect, or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by us to make such requests. For a request form, please contact the Privacy Officer.
  • You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to exceed six years), as required by law. We ask that such requests be made in writing on a form provided by us. Please note that accounting does not include all disclosures, e.g., disclosures to carry out treatment, payment, or healthcare operations and disclosures made to you or your legal representative or pursuant to an authorization. You will not be charged for your first accounting request in any 12-month period. However, for any requests that you make thereafter, you will be charged a reasonable, cost-based fee.
  • You have the right to be notified following a breach of your unsecured protected health information.
  • You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.

For More Information or to Report a Problem

You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint. For more information or to file a complaint with us, contact our Privacy Officer by phone or mail as

To file a complaint with the Secretary of HHS, send your complaint to:

PRINCE GEORGE'S COUNTY HUMAN RELATIONS COMMISSION
1400 McCormick Drive, Suite 245
Largo, MD 20774

[INSERT EFFECTIVE DATE OF THE NOTICE]

BRENT FREY,DDS

Specialist in Orthodontics &
Dentofacial Orthopedics

RELEASE AUTHORIZING USE OF PERSONAL LIKENESS

I, (patient name) consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Champion Smiles for any lawful use Champion Smiles deems appropriate, including for treatment, advertising his/her/its services to the general public (including via social media and electronic media), illustration, and publication to the public at large for educational purposes.


I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Champion Smiles during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.


I understand any image or likeness of me may be altered prior to use if deemed appropriate by Champion Smiles. I understand and agree that I have no right to be consulted about or approve of any such alterations before my image is used.


I understand and agree that Champion Smiles may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment re

ndered to me as depicted in any image of me.


I understand that Champion Smiles may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.


I have read the foregoing in its entirety and understand its terms.

Prince George's Metro Center ||| | 6525 Belcrest Road, Suite 290 | Hyattsville, MD 20782
North Oak Professinal Center | 3060 Mitchellville Road, Suite 108 | Bowie, MD 20716
301-249-4123 | info@smile-champs.com | www.smile-champs.com