Please provide a response to all:
Please circle if patient has or has had…
Any injuries to:
By signing the following, I certify that all information listed above is correct and I grant permission to Dr. Jeffrey
Mastroianni to take records for the purpose of making a proper diagnosis and treatment plan for the patient listed above.
These records include a panorex, lateral cephalogram, digital photos, models of the patient’s teeth, and other diagnostic
aids. I understand that it is not possible to begin orthodontic treatment without gathering all of the necessary records