I certify that the above information is correct and that this office will not be held responsible for situations arising out of inadequate information
of information not disclosed. I authorize Heidi Harman Orthodontics, LLC to share any and all of this patient’s diagnostic records, images,
photos, etc. and pertinent information with doctors, dentists, surgeons, and insurance companies or any individual or entity necessary to
provide and complete care for this patient. I was offered a copy of this office’s Notice of Privacy Practices/HIPAA disclosure.