Sudbury Informed Consent Form

Informed Consent Form
Patient's Name*

First NameMiddle NameLast Name
InvisalignOrtho ClearOthers
SelfParent / Guardian
Responsible Party's Name*

First NameMiddle NameLast Name

Invisalign Treatment
We need your permission to use all the components of the Invisalign system, as well as your commitment to full-time (22hours/day) wear of the aligners.

Attachments

For certain types of movements, aligners can lose their grip on a tooth and fail to get the desired tooth movement. To overcome this, Align Technology custom designs small tooth-colored bumps that are temporarily and precisely bonded to some teeth to improve the effectiveness of the aligners and tooth movement. A small bubble in your aligner will correspond precisely to each of these attachments.

Invisalign Full Conditions

The Clincheck Video simulation is only a guide to what we can expect and not a guarantee that will be achieved. Compliance and care of your aligners well can help.
Aligners should be worn for at least 22 hours out of 24 to achieve the best results.
It is important to make all of your scheduled visits to our office. This will allow us to check your progress and deliver new aligners.
You may be required to wear elastics to correct certain tooth movements or help with bite correction. Elastics should be worn as directed by your orthodontist.
Aligners may be used in conjunction with different appliances to aid in bite correction (i.e Herbst appliance). Compliance with both is essential for optimal tooth movement and results.
If you have poor compliance with either aligner or elastics or poor tooth movement with your aligners, braces (in conjunction with other appliances) may be required.

Interproximal Reduction (IPR)

Interproximal reduction (IPR) is filing between your teeth to create up to a quarter of a millimeter (0.25mm) of space per tooth surface. Since this is the thickness of a few pieces of paper it is generally not even noticeable. The filing is usually done with a thin strip of metal that has fine diamond particles. Dentists use this to polish fillings between teeth so it will feel like we are polishing in between your teeth with floss that is gritty. IPR is very valuable because a small amount of IPR on a number of teeth can create space needed to correct crowding without extracting any teeth. IPR reduces friction between tight teeth facilitating movement. IPR can render better tooth shape and broader contact between teeth. This may be more stable, more aesthetic and even enable better periodontal health. IPR may help avoid extractions as an alternative to create space.

Refinement

At the end of treatment, we may order further aligners for ensuring that the outcome with your smile is as close to being perfect as possible. With a "Full Invisalign Case" there are three refinements available at no charge if ordered within 6 months of finishing the initial treatment.

Retention

At the end of the treatment, we recommend the use of retainers to keep your teeth from shifting back to their original position. We recommend permanent, fixed. I understand teeth can shift if retainers are not used.
Clear Aligner Treatment
We need your permission to use all the components of the clear alginer system, as well as your commitment to full-time (22hours/day) wear of the aligners.

Attachments

For certain types of movements, aligners can lose their grip on a tooth and fail to get the desired tooth movement. To overcome this, aligners are custom designed as small tooth-colored bumps that are temporarily and precisely bonded to some teeth to improve the effectiveness of the aligners and tooth movement. A small bubble in your aligner will correspond precisely to each of these attachments.

Clear Aligner Full Conditions

The Clincheck Video simulation is only a guide to what we can expect and not a guarantee that will be achieved. Compliance and care of your aligners well can help.
Aligners should be worn for at least 22 hours out of 24 hours to achieve the best results.
It is important to make all of your scheduled visits to our office. This will allow us to check your progress and deliver new aligners. You may be required to wear elastics to correct certain tooth movements or help with bite correction. Elastics should be worn as directed by your orthodontist. Aligners may be used in conjunction with different appliances to aid in bite correction (i.e Herbst appliance). Compliance with both is essential for optimal tooth movement and results. If you have poor compliance with either aligners or elastics or poor tooth movement with your aligners, braces (in conjunction with other appliances) may be required.

Interproximal Reduction (IPR)

Interproximal reduction (IPR) is filing between your teeth to create up to a quarter of a millimeter (0.25mm) of space per tooth surface. Since this is the thickness of a few pieces of paper it is generally not even noticeable. The filing is usually done with a thin strip of metal that has fine diamond particles. Dentists use this to polish fillings between teeth so it will feel like we are polishing in between your teeth with floss that is gritty. IPR is very valuable because a small amount of IPR on a number of teeth can create space needed to correct crowding without extracting any teeth. IPR reduces friction between tight teeth facilitating movement. IPR can render better tooth shape and broader contact between teeth. This may be more stable, more aesthetic and even enable better periodontal health. IPR may help avoid extractions as an alternative to create space.

Refinement

At the end of treatment, we may order further aligners for ensuring that the outcome with your smile is as close to being perfect as possible.

Retention

At the end of the treatment, we recommend the use of retainers to keep your teeth from shifting back to their original position. We recommend permanent, fixed. I understand teeth can shift if retainers are not used.
Risks and Limitations Of Orthodontic Treatment
Successful orthodontic treatment is a partnership between the orthodontist and patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should seriously consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.

I Understand
Results Of Treatment
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist’s instructions carefully.

I Understand
Length Of Treatment
The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth and the level of patient cooperation. The actual treatment time is usually close to the estimated treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary.

I Understand
Discomfort
I Understand
Relapse
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Minor irregularities, particularly in the lower front teeth, may have to be accepted.

I Understand
Extractions
I Understand
Orthognathic Surgery
Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you should discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment.

I Understand
Decalcification and Dental Caries
I Understand
Root Resorption
The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients have retained teeth throughout life with severely shortened roots. If resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the completion of treatment.

I Understand
Nerve Damage
I Understand
Periodontal Disease
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitors your periodontal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.

I Understand
Injury from Orthodontic Appliances
Activities or food which could damage, loose or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled or swallowed. You should inform your orthodontist as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc) is possible when orthodontic appliances are removed. This problem may be more likely when aesthetic appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

I Understand
Temporomandibular Joint Dysfunction
Problems may occur in the jaw joints causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Any jaw joint symptoms should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.

I Understand
Impacted, Ankylosed Unerupted Teeth
Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circumstances and the overall importance of the involved tooth, and may requires extraction, surgical exposure, surgical transplantation or prosthetic replacement.

I Understand
Occlusal Adjustment
I Understand
Non – Ideal Results
I Understand
Allergies
I Understand
General Health Problems
I Understand
Use of Tobacco Products
I Understand
Temporary Anchorage Devices
Your treatment may include the use of a TAD. There are specific risks associated with them. It is possible that the screw(s) could become loose which would require its/their removal and possibly relocation or replacement with a larger screw. The screw and related may be accidentally swallowed. It is possible that the tissue around the device could become inflamed or infected, or the soft tissue could grow over the device, which could also require its removal, surgical excision of the tissue and/or the use of antibiotics or antimicrobial rinses. It is possible that the screws could break (i.e upon insertion or removal). If this occurs, the broken piece may be left in your mouth or may be surgically removed. This may require referral to another dental specialist. When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary. Local anesthetic may be used when these devices are inserted or removed. Please advise the doctor placing the device if you have had any difficulties with dental anaesthetics in the past. If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.

I Understand
Consent to Undergo Orthodontic Treatment
I Understand
Authorization For Release Of Patient Information
I Understand

Acknowledgement
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the orthodontist to provide the treatment. I also authorize the orthodontist to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by the orthodontist, and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.

I Understand
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Informed Consent Form

Invisalign Treatment

Clear Aligner Treatment

Risks and Limitations Of Orthodontic Treatment

Results Of Treatment

Length Of Treatment

Discomfort

Relapse

Extractions

Orthognathic Surgery

Decalcification and Dental Caries

Root Resorption

Nerve Damage

Periodontal Disease

Injury from Orthodontic Appliances

Temporomandibular Joint Dysfunction

Impacted, Ankylosed Unerupted Teeth

Occlusal Adjustment

Non – Ideal Results

Allergies

General Health Problems

Use of Tobacco Products

Temporary Anchorage Devices

Consent to Undergo Orthodontic Treatment

Authorization For Release Of Patient Information

Acknowledgement

Social Media Consent