I acknowledge that my doctor and Align Technology, Inc. headquartered in San Jose, California (“Align”) have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Align is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give medical advice. No assurances or guarantees of any kind have been made to me by my doctor or Align, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment.
I understand and consent to my doctor collecting and using my medical records, including, but not limited to, radiographs (x-rays), reports, charts, medical history, photographs, findings, plaster models, impressions of teeth, or intra-oral scans, prescriptions, diagnosis, medical testing, test results, ethnicity, billing, and other treatment records in my doctor’s possession (“Medical Records”) to the extent necessary for treatment, customer service, and billing. If I do not provide my consent to these uses of my Medical Records then I may not be able to receive Invisalign treatment.
I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not nor shall anyone on my behalf have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.
A copy of this Consent shall be considered as effective and valid as an original. I have read, understand and agree to the terms set forth in this Consent as indicated by my signature below.