Responsible Party Information
I understand that where appropriate, credit bureau reports may be obtained.
Benefits of Orthodontics: Aesthetics, Health and Function. Orthodontics is a service that provides an improvement in the appearance of teeth, in the general
function of teeth, and in the general dental health. Teeth, gums, and jaws are an intricate body part and can fail to respond to treatment. If good oral hygiene
is not practiced, tooth decay and enlarged gums can result. Joint discomfort and root shortening are observed in a small percentage of cases. Teeth change
throughout our lifetime and there can be some movement of teeth and some change after treatment. I have read and understand this paragraph, I also understand that my diagnostic records and my name may be used for educational and promotional purposes. I have truthfully answered all the above questions and
agree to inform this office of any changes in my medical or dental history. In addition, I authorize Dr. Gutiérrez to perform a complete orthodontic evaluation.