WP E-Signature by Approve Me - Sign Documents Using WordPress -

Early Termination of Treatment

Patient Name:

Parent/Guardian Name:

Patient Address

Street Address:

Address Line 2:

City: State: Zip Code:

This letter is to certify patient/patient’s parent/patient’s guardian request the removal of orthodontic appliances and the termination of treatment.

Patient/Patient’s parent/Patient’s guardian has been informed that treatment has not been completed and that Won-Woo Park, DMD, MS recommends the continuation of treatment in order to obtain the best results.

I hereby release Won-Woo Park, DMD, MS, OoLi Orthodontics – AZ PHX, PC & OoLi Orthodontics - AZ Tempe, PC from any responsibility for all consequences caused by early termination of treatment.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw Signature
Type In Signature

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Adopt & Sign

Timestamp

Audit

August 14, 2020 10:42 am MST

Early Termination of Treatment Uploaded by Won-Woo Park - forms@ooliortho.com IP 70.163.243.141

January 15, 2023 9:00 pm MST

OoLi Forms - forms@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141

January 15, 2023 9:00 pm MST

WW Jonathan Park, DMD, MS - drpark@ooliortho.com added by Won-Woo Park - forms@ooliortho.com as a CC'd Recipient Ip: 70.163.243.141