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 dental needs.

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.