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We Smiles Pty Limited PATIENT ELECTION AND WAIVER

I understand: (a) That to receive invisible dental aligners with We Smile I must have, or have had, an OPG x-ray within the last six (6) months; and (b) I am only permitted to select one option below which will be relied upon by We Smile for the purposes of assessing my suitability for the services it offers. I confirm the option I select below accurately reflects my current circumstances (must be completed):

I understand that if the option I select above does not represent my current circumstances then We Smile can, at any time: (a) terminate the services it offers to me; and (b) will not be responsible for any loss, damage or harm suffered by me as a consequence of the information I have provided. I confirm I am aware of the risks of receiving treatment for invisible dental aligners and I have read the Patient Information Sheet. Acceptance I confirm I, , have read and understood this Patient Election and Waiver Form and all the information I have provided is accurate.

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October 31, 2018 12:54 pm AEST

We Smiles Pty Limited PATIENT ELECTION AND WAIVER Uploaded by Mel Licker - [email protected] IP 2405:204:8209:d835:9865:31cd:2b4a:5d09