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I/We acknowledge and agree that the office of Dr. Eggert Boehlau can collect, use and disclose personal information about me/my child to assess my/his/her health needs and risks, and to provide safe and efficient orthodontic care. In addition, 1/We authorize the office of Dr. Boehlau to communicate with other treating health-care providers, including other specialists and general dentists, and/or referring dentists, physicians, pharmacists, as well as third_party insurance carriers.