I, the undersigned, do hereby request and give my permission to Deepa Vyas, D.M.D. and Vyas
Orthodontics to provide other health care providers and insurance companies any and all
information with respect to my dental care. Such records may include medical care and treatment,
illness or injury, dental history, medical history, consultation, prescriptions, xrays, models
and copies of all dental and medical records.
I, the undersigned, do hereby relinquish any and all rights to photographs, portraits, prints,
or other photographic reproductions captured with still, motion picture, video, digital or other
cameras for use by Deepa Vyas, D.M.D. and Vyas Orthodontics. Unless images are used to
communicate with another care provider, no names, birthdates or identifiable information will be
linked to any image.