1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

By signing this form, you indicate that you have the legal authority to request and access these records and authorize us to send them to the person/clinic that you indicate via email or for pick up. You release Synergi Orthodontic Specialists and any associates/employees from liability in the process. While our practice does our absolute best to keep your data secure, you understand that sending records via email can never be fully secure and can be intercepted by a number of ways including but not limited to security breaches, typographical errors, etc. You understand that our practice can take up to 5 days from receipt of this form to send or prepare these records. Our first priority is patients scheduled in the office, so records requests come secondary to immediate patient care. I understand that if I request patient records and Synergi Orthodontic Specialists is unable to verify authorization based on the patient consent forms we have on file in our practice management system, that Synergi Orthodontic Specialists will not release the records.