Treatment Terminated Due To Non-Compliance: Orthodontic treatment requires the full cooperation of the patient and/or responsible party with the orthodontist to achieve a successful outcome. If Dr. Shaw determines that the patient (or responsible party) is unable or unwilling to cooperate with instructions or fails to listen, understand or comply with treatment instructions, office policies, or other obligations, then Dr. Shaw reserves the right to terminate orthodontic treatment due to non-compliance. Termination for noncompliance may be the result of the patient and/or responsible parties behavior, but it may also result from parental failure to supervise a child’s care at home, to attend orthodontic visits with the child, and to ensure that all oral hygiene and other instructions are understood and complied with. Dr. Shaw reserves the right to terminate at any point without explanation, details, or consultation.
Treatment Terminated Due To Non-Payment: If Dr. Shaw terminates your treatment for non-payment, we will (1) cancel any payment plan you are under; (2) bill your insurance for any outstanding balance, if applicable; (3) remove your braces at your request or transfer your case to a qualified Orthodontist at your request; (4) cancel all future appointments with us; (5) assess an early termination fee, if applicable.
Treatment Terminated Due To Poor Oral Hygiene: If the patient does not maintain good oral hygiene, Dr. Shaw will first seek to show you how to do a better job. If you are still unable to maintain good oral hygiene, Dr. Shaw, may, in his sole discretion, remove the orthodontic appliances, and end the treatment for your own health and safety- poor hygiene is especially detrimental to teeth undergoing orthodontic treatment.
Treatment Termination for Clinical Mistrust: Dr. Shaw reserves the right to terminate treatment at any point if the patient, responsible party, or any parent, relative or other person associated with the patient, adopts any posture or uses any language that the orthodontist deems threatening, insulting, discriminatory or offensive towards the orthodontist, staff, and/or practice. Such behavior violates the trust and cordial relationship that is necessary between patient and clinician and will result in termination of the orthodontic treatment plan.
In consideration of, among other things, said Doctor’s agreement to remove my child’s appliances at my request and such removal, the sufficiency of which is hereby acknowledged, I do hereby, on behalf of my child, and all those who may now or in the future have any interest in the care and treatment of my child, now and forever release and discharge said Doctor, his/her agents, employees, professional corporation, insurers and assigns from any loss, costs, damages or expenses arising out of the removal of my child’s appliances as aforesaid. I understand that this is a full waiver and release of any and all claims my child or anyone claiming through or on behalf of my child may now have or may acquire in the future arising out of the removal of my child’s appliances as aforesaid by Dr. Shaw, his agents or employees. I further understand that, by executing this Release and Waiver and said Doctor’s agreement to remove my child’s appliances at my request and such removal, my child and anyone claiming through or on behalf of my child will be forever foreclosed from any claim for damages arising out of or related to the removal of said appliances as aforesaid. This Release and Waiver is the entire agreement between Dr. Shaw and the undersigned party. The undersigned, in executing this Release and Waiver, acknowledges that the consideration recited herein is the consideration for the full and final release and waiver contained herein, and that no other understandings or agreements, representations or promises, verbal or otherwise, have been relied upon by the undersigned in executing this Release and Waiver.
I understand that my child’s orthodontic treatment is being terminated early due to one or more of the listed reasons above. I have had the opportunity to ask any questions & I have had those questions adequately answered. further understand that treatment is not completed at this time, and has not met the original goals when the treatment was started.