Mentor Request Form

By signing this form, you acknowledge that you must adhere to all laws and regulations applicable to the mentor program, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which requires authorization to use and disclosure protected health information in connection with the program.

You agree that the International Association for Orthodontics is not liable for treatment results and outcomes, and you hereby release the IAO, its employees, agents, and representatives from all claims for damages resulting from your participation in the mentor program. You further agree to indemnify, defend, and hold the IAO harmless from any and all claims, suits, actions or proceedings of any kind arising out of, or in connection with your participation in the mentor program, including any claims relating to advice or guidance given in connection with the program.