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i smile orthodontics

Authorization for a Third Party to Discuss Treatment & Financials

I hereby authorize,

to act as my agent to discuss care or treatment which is recommended by Dr. Stiles and to consent to any (but not limited to) x-rays, photos, examination, orthodontic diagnosis or treatment to be rendered by Dr. Rachel Stiles which may incur treatment/diagnosis fees. All financial information concerning my account/treatment may also be discussed with the above-named party. 

I understand that this authorization may be given in advance of any specific diagnosis or treatment and is given to provide authority to the abovenamed agent to give consent to any and all such diagnosis or treatment or care that a licensed orthodontist recommends. This authorization is given pursuant to the provisions of Family Code Section 6910.

This authorization shall remain effective indefinitely unless revoked in writing and delivered to the doctor at the above address. 

Thanks for submitting!

third party

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