Parent Authorization Form

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Parent Authorization Form

* The parties agree and understand that this request, waiver and release is entered into with Dr. Bradley F. Kendzior, Kendzior Orthodontics, P.C. and the parties agree and understand that majority and minority refers tot the period of time, respectively after, and before, the minor child reaches age 18.
    We understand that KENDZIOR ORTHODONTICS, P.C. is providing a free service via "BRACE EXPRESS" to pick up and deliver our child to and from school without any cost or charge for the purpose of facilitating or securing necessary orthodontic care for our child.
    We understand and agree the KENDZIOR ORTHODONTICS, P.C. and "BRACE EXPRESS" have sole and exclusive right and authority to make all decisions regarding our child riding on the "Brace Express" including but not limited to the hours, terms and conditions of initial and continued service.
    The "BRACE EXPRESS" is designed for regular appointments. if there are LOOSE or BROKEN appliances, we will ask that the child be brought to his/her appointment by a different means of transportation.
    Recognizing that we as parents and our child are participating, in and benefiting from this service, which we agree and declare to be a necessary medical health related service, we are parents release and forever discharge, KENDZIOR ORTHODONTICS, P.C., its employees, agents, representatives, drivers, heirs and assigns from any and all claims, causes or action, suits, damages or injuries arising out of or in any way connected with my child participating in the "BRACE EXPRESS" service and any and all aspects or derivatives thereof, specifically including our right to sue for medical expenses and loss of services during our child's minority*
    I, the minor child, do hereby release and forever discharge KENDZIOR ORTHODONTICS,P.C., its employees, agents, representatives, drivers, heirs and assigns from any and all claims, causes of action, suits, damages or injuries arising out of or in any way connected with me participating in the "BRACE EXPRESS" service and any and all aspects or derivatives thereof, specifically including my right to sue, both now, and at any time after reaching majority*, for any and all pain and suffering, and for any loss after minority*.
    We, the undersigned, further release and forever discharge KENDZIOR ORTHODONTICS, P.C., its employees, agents, representatives, drivers, heirs, and assigns from any and all claims, causes of action, suits, damages or injuries arising or in any way connected with the child riding "BRACE EXPRESS", including but not limited to, the selection of the operator, the condition of the vehicle, the manner of operation of the vehicle, the conduct of the operator of the vehicle and/or any other children taking advantage of this service, and for any and all other claims, causes of action, suits, damages or injuries arising out of, or in any way connected with, our use of the "BRACE EXPRESS" to receive medical necessary orthodontic services.
    We, the undersigned, certify that we have read this entire form, understand it, agree to it, and by our signatures below evidence our intention to be legally bound to it and all representation made in it.
  • *typing your full name will account for signing this document *type N/A if you are a legal guardian
  • *typing your full name will account for signing this document *type N/A if you are a parent
  • *typing your full name will account for signing this document