I (or authorized representative/guardian) hereby authorize Dr. Konz to
take x-rays, study models, photographs and/or any other diagnostic aids
deemed appropriate by the doctor to make a thorough diagnosis of the patient’s
Upon such diagnosis, I authorize Dr. Konz to perform all recommended treatment
mutually agreed upon by me and to employ such assistance as required to
provide proper care. I agree to the use of anesthetics, sedatives and other
medication as necessary. I fully understand that using anesthetic agents
embodies certain risks. I understand that I can ask for a complete recital
on any possible complication.
I hereby give Dr. Konz the absolute right and permission to use my photographs
for educational or promotional purposes. The undersigned completely and
forever releases any right to present or future compensation in connection
with the use of said photographs.
I have read and understand the above information.