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7655 Five Mile Road Suite 207 Cincinnati, OH 45230
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513-232-4110 Fax: 513-232-4949
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info@drromick.com
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CONSENT FORM FOR OFFICE PARTICIPATION
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Dr. Romick and his staff are committed to truly getting to know their patients. Patients are known by their names, their interests, hobbies and involvement in their communities. We also realize that orthodontic treatment is a significant event in the lives of our patients. We enjoy recognizing these special moments by including names of our patients on a bulletin board in our office waiting area. In addition to this, we also wish to be updated on the accomplishments and achievements of our patients. The front office staff reviews local newspapers and periodicals in order to discover positive and exciting articles regarding our patients. We also invite you, as the patient or responsible party, to share with us so that we may get to know you better!
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The following release authorizes the office of Dr. Brian W. Romick to post the name and relevant information regarding the patient on our waiting room bulletin board, website, office “Wall of Fame,†and/or patient welcome albums.
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