Cosmetic Dentistry
Tuesday, May 31st, 2011 Category: Patient Education No Comments 
Are you interested in cosmetic dentistry? Please check the aspects of your smile that you would like to change:
[ ] Whiter teeth
[ ] Replace missing teeth
[ ] Remove stains
[ ] Straighter teeth
[ ] Replace chipped teeth
[ ] Replace old plastic fillings
[ ] Other ____________________________________
[ ] Close space or spaces
[ ] Replace old crowns
[ ] Excess showing of teeth
[ ] Less gum showing
[ ] Remove silver fillings
[ ] Reshape or resize teeth
Photographic Release
In our office we like to photograph our patients to aid Dr. Marye in determining dental problems and the solutions/treatment options for them. Dr. Marye sometimes uses the photographs, with the patient’s permission, for display. We are very proud of the work we have done and use only our own patient’s photographs in our marketing and advertising. All of the portraits in our office and on the website (www.smiles of texas.com) and in our ads are our own patients.
Authorization and release:
I hereby authorize Dr. Marye to use photos of my face, jaws, and teeth. I understand that the photos may be used as a record of my care and may be used for educational and advertising purposes. (Including website, magazines, phonebooks, television and professional publications). I further understand that if my photos are used in any way described above that my name and identifying information will be confidential. I do not expect compensation, financial or otherwise for use of these photos.
X-ray Information
X-rays provide invaluable information for Dr. Marye for diagnosing and treatment planning. To provide a comprehensive examination, x-rays are required. There are a variety of x-rays; each provides a variety of information. Dr. Marye will recommend x-rays based on your individual needs. Our x-ray system is digital which results in the lowest possible exposure to radiation. We are able to view the films immediately.
Insurance companies limit the types and the frequency that some x-rays are taken. It is our responsibility to provide a comprehensive evaluation to you. By limiting the allowance of x-rays, Dr. Marye cannot present a signed release of liability from you stating that you fully understand that there are conditions that cannot be diagnosed without them.
I have read the information regarding x-rays and fully understand Dr. Marye’s philosophy. I understand that my insurance company limits frequency of some types of x-rays and if I am in a situation that requires services not covered, I will be responsible for the fees associated with the service.
Patient signature: _________________________________ Date: ________________________
