I hereby consent to allow the office of Dr. Colin Mihalik to perform radiologic services as ordered and recommended by my dentist.
The risks of submitting to radiologic services, including x-rays, have been fully explained to me by my dentist. I have discussed the need for these radiologic services with my dentist, and I agree to undergo the radiologic services recommended by dentist.
I understand the office of Dr. Colin Mihalik has made no recommendations regarding the need for these radiologic services or the type of radiologic services to be performed.
I understand that the office of Dr. Colin Mihalik will provide no professional interpretation of the radiologic images obtained on the order and recommendation of my dentist. I further understand that Dr. Colin Mihalik will provide no treatment and will make no recommendations for treatment based on these radiologic studies to either me or my dentist.
I understand that the office of Dr. Colin Mihalik is only providing a technical service to my dentist by allowing my dentist to utilize the radiologic equipment operated by the office of Dr. Colin Mihalik. I hereby authorize the office of Dr. Colin Mihalik to provide my radiologic studies and related health care information to my dentist for his/her sole professional interpretation.
I understand that I am responsible to pay the fee of 150.00 on the day service is rendered.