CONSENT FORM FOR ORTHODONTIC TREATMENT

I, ____________________________, of legal age authorized Dr. Bushra

Nosherwani to remove my braces for the treatment was completed. I went to this
clinic to my own will and decide Dr. Bushra Nosherwani to handle the removal of
my braces.

I certify that I fully understand the above authorization and information consent
to remove my braces, anticipated limitations, risks and drawbacks which have
been explained to me and that all of my questions, if any, have been answered.