Child Start Form

1. Numerous factors must be considered when planning orthodontic treatment. Some of the points discussed at the initial examination appointment may be forgotten or not fully understood so we have made this handout to highlight some of the important points.

2. Practice Scope: Our practice is limited to the specialty of Orthodontics & Dentofacial Orthopedics. We will call your attention to any problems we may find, but we do not provide general dental work (i.e. cleanings, restorations for cavities, etc...). It will be necessary to continue regular dental checkups with your general dentist during orthodontic treatment (every 3-6 months). Additionally, it is up to the responsible party to be aware of all associated costs for procedures that will be performed by a general dentist and/or dental specialist (i.e. removal of teeth, veneers, crowns, bridges, implants, etc..), which are not part of the covered orthodontic treatment fee.

3. OSHA & HIPAA: All state and federal OSHA regulations are strictly adhered to. Our office maintains the privacy of the patient’s personal information through compliance with HIPAA regulations. Due to HIPAA regulations only patients are allowed in the treatment area (excluding the initial exam, new patient oral hygiene instructions and at the request of Dr. Shaw or the staff).

4. Treatment Plan: The treatment plan discussed at the new patient exam is a preliminary plan only. Based upon evidence gathered from full orthodontic records, modifications may be made to the original treatment plan. Changes to the original treatment plan will be discussed with the patient/parent before the appliances are placed. Additionally, changes may be made to the treatment plan at any time during active treatment in order to give the patient the best result possible. The patient/parent will be notified of any treatment plan changes and have the opportunity to accept or refuse the proposed changes. Dr. Shaw develops a custom treatment plan for each patient. For treatment to be as efficient as possible and to ensure the best possible result, Dr. Shaw will decide on the timing and sequence in which to place the brackets and deliver appliances. Most patients will not get all their braces at the first appointment, rather they will be added incrementally over time as Dr. Shaw sees fit.

5. Treatment Time & Result: Treatment time will be estimated at the initial exam, however this is an estimate only. Actual treatment time and treatment results are dependent upon many factors. Orthodontic treatment requires a commitment from the patient in order to achieve the best result possible. Patient factors that affect treatment time and treatment results include (but are not limited to): growth (i.e. jaws and teeth), habits, muscle changes, patient compliance and anatomical variation of teeth (i.e. shape, size, color and composition). Abnormal growth and/or lack of cooperation by the patient in any of these areas in addition to Dr. Shaw’s treatment recommendations may result in prolonged treatment time, compromised results, early removal of the braces and/or additional charges.

6. Cooperation with Treatment: We will advise the patient and/or parents when an area of cooperation needs improvement. Repeated non-compliance in any of these areas below will subject the patient to an increased treatment time, compromised result, additional charges to replace broken appliances and/or early removal of all appliances at Dr. Shaw’s sole discretion. If treatment time is prolonged due to non-compliance from the patient, you will be responsible for charges associated with the additional treatment time.

• Appointments: We understand that “things happen” and patients may show-up late for their appointment. In these situations we will do our best to see you but please understand that our office will give priority to on-time patients before we attempt to see any late patients. We recommend that late patients reschedule if they do not have time to wait.
• Broken Appliances: Even with excellent patient compliance broken appliances are a part of orthodontic treatment. Our office will do our best to replace broken brackets as soon as possible. However, unless you are already scheduled for a longer appointment expect that we will have to remove the broken bracket and reschedule you at your earliest convenience to put it back on as shorter appointments do not allow the necessary time to properly replace the bracket. Additional charges may be incurred for lost, loosened or broken appliances.
• Lost Appliances During Treatment: This applies to removable appliances (ie. Retainers, expanders, etc) We understand accidents happen, and are happy to replace any appliance free of charge the 1st time the appliance is lost/broken. After the first replacement the lab bill to replace the appliance will be passed on to the patient/parent, and will become their responsibility.
  • Please note that repeated replacements/repairs will be subject the patient to an increased treatment time, compromised result, and additional charges to replace broken/lost appliances and/or early removal of all appliances at Dr. Shaw’s sole discretion. If treatment is prolonged due to repeated replacements/repairs, you will be responsible for charges associated with the additional treatment time.
  • Please see below the list of fees that will be charged accordingly.
    • $25 per broken bracket
    • $125 Retainer Replacement w/ 3D printed model rendered
    • $250 Retainer Replacement with out 3D printed model
      • Lab bill associated with replacement appliance or aligner series remakes will be passed on to the patient/parent. Bill can range between $100-$350.
      • Extended treatment time: $189 per month until treatment is completed.
• Oral Hygiene: We may ask patients and/or parents for help in obtaining better brushing and flossing habits as well as assuring proper wear and care of the braces and/or prescribed auxiliary appliances.

7. Scheduling/Rescheduling: The patient and/or parent(s) is/are solely responsible for maintaining regularly scheduled appointments. As our practice works primarily with children, it is sometimes necessary that we see our patients during school hours. There may be times when an orthodontic appointment will have to take priority over school activities. In the past, we have found that schools are cooperative in this matter. We understand that your time is valuable, so in an effort to ensure complete patient and parent satisfaction Dr. Shaw requires that all patients schedule longer appointments (>30 minutes) during the middle portions of each day. For many patients treatment usually consists of a handful of longer appointments (i.e. adding braces, bonding Invisalign attachments, delivering appliances, etc...) that tend to be at the beginning and end of orthodontic treatment. The more popular before and after school appointment times are reserved for quicker appointments (

8. Invisalign: Excellent compliance with the Invisalign treatment plan is required for the aligners to work properly. Keep all aligners and do not throw them away. In some cases we need to go back and use them again.

• Midcourse Correction: If compliance with the Invisalign treatment plan is adequate and treatment is not tracking properly then we can do a Midcourse Correction.
• Refinement: If the first series of aligners have been completed, but additional tooth movement is needed, we can do an Invisalign Case Refinement.
• The Midcourse Correction or the Invisalign Case Refinement typically involve taking new scans of the teeth as well as updated photographs. A new series of Invisalign aligners is then dispensed to the patient. For Invisalign Full & Teen: Midcourse Corrections or Case Refinements are included with your orthodontic treatment. For Express 5, 10 or Lite Invisalign: If additional Midcourse Corrections or Case Refinements are needed then an additional charge will be applied of $500 each. If dental work is performed during Invisalign treatment that prevents the Invisalign aligners from fitting properly than an additional charge of $500 is incurred in order to have a new set of aligners fabricated

9. Retainers: When the treatment is completed all appliances will be removed and retainers will be custom made for the patient. Properly worn retainers ensure that the final result upon removal of the appliances will be maintained. Improper retainer wear due to the loss of the retainers and/or broken retainers will cause shifting of the teeth. Re-treatment fees to correct shifted teeth due to improper retainer wear are the sole responsibility of the patient/parent and not our office. Each patient is given the choice between the following 2 retainer options:

a. Extended Retainer Program (additional $695 Enrollment Fee): This program is offered at every initial exam. The program includes:

• 3D Scan of Teeth
• 4 set of retainers (4 upper retainers & 4 lower retainers)
• 3D Printed Models (1 upper model and 1 lower model)

b. In House Retainer Program. This program comes with every treatment plan. This program includes the following:

• 3D Scan of Teeth
• 1 set of retainers (1 upper retainer & 1 lower retainer)
• 3D Printed Models (1 upper model and 1 lower model)

c. REPLACEMENT FEES for either program

• $125 per replacement retainer with 3D printed model provided to us by patient
• $250 replacement fee if patient is unable to provide 3D printed model(s). This will include 1 set of retainers & 1 set of 3D printed models. 50% off of the replacement fee if only 1 3D printed model has been lost or destroyed

*** The bonded retainer(s) (if applicable) will be repaired for no charge if/when it breaks the first time. If the bonded retainer(s) breaks after the first repair, Dr. Shaw may assess the pre-determined charge to repair the bonded retainer or decide to have a removable retainer made instead.

10. Treatment Fee: All fees charged through this office are the responsibility of the patient, parents and/or guardian, regardless of the insurance coverage. The treatment fee includes: a comprehensive examination, x-rays, photographs, models of the teeth, all appliances and office visits during the corrective treatment period, placement of the retaining appliances, and retainer check appointments for a one year period following removal of the braces. After that, a per-visit charge will be assessed (excluding Phase I patients that return to the office for growth check appointments).

11. Insurance: If the patient has insurance coverage with a managed care organization with which this office has contractual agreement, we will submit your dental insurance claims at no extra charge to you. Any available orthodontic benefits will be paid directly to our office. If for any reason the estimated insurance benefit is denied, not received and/or not paid by your insurance carrier (for procedures and/or appliances before, during and/or after orthodontic treatment), the remaining balance becomes your responsibility.

12. Payment: The responsible party agrees to pay all applicable copayments and deductibles, which arise during the course of treatment for the patient. The responsible party also agrees to pay for the treatment rendered even if the treatment is not considered to be a covered service by a third party insurance company. If your account is on a monthly schedule, payment is due every month regardless of your appointment schedule. We expect you to pay your portion of the bill on or before the day services are rendered. Failure to keep this account current will result in dismissal from the practice and the inability to receive additional services except for emergencies. Any refund made to the patient is solely at the discretion of our office.

13. Transfers: Patients are heavily discouraged to transfer during active treatment. Transferring during treatment can potentially extend treatment time and increase your overall treatment fee. If the patient decides to transfer during treatment, the policy for determining the refund amount due to the responsible party or payment due to our office by the account holder will be based on the following pro-rata:

• BRACES/APPLIANCE TREATENT: 20% Of Total Case Fee = Initial Placement Of Appliances (this is not necessarily your down payment amount) + Any Monthly Payment(s) You Have Made To The Office Or Will Make Up Until Transfer Date.
• INVISALIGN TREATENT: 30% Of Total Case Fee = Initial Placement Of Appliances (this is not necessarily your down payment amount) + Any Monthly Payment(s) You Have Made To The Office Or Will Make Up Until Transfer Date.

***You are always welcome to ask questions or discuss treatment progress with Dr. Shaw. We want this to be an enjoyable experience for everyone. We are glad you are here and look forward to giving you the smile you deserve!

What good are straight teeth if they have cavities?!?! “White Spot Lesions” are a type of early (but permanent) cavity that forms in orthodontic patients when home care is not good. If we ever notice that your home care might be causing damage to your gums or teeth, we are going to take the following steps:

The 1st warning will be given when we notice the gum tissue starting to become irritated and puffy. We will provide oral hygiene instructions with the hope that you will turn things around.

The 2nd warning will be given when there has been minimal or no improvement in oral hygiene habits since last appointment. We will provide oral hygiene instructions again, with the hope you’ll turn things around.

The 3rd and FINAL warning will be given when has been minimal or no improvement in oral hygiene habits since last appointment and there are signs of permanent “white spots” forming on your teeth. We will provide oral hygiene instructions again, but this time we will be removing the wires from your braces. You will have to return to our office in 2-3 weeks for another oral hygiene check.

Braces removal will occur if no oral hygiene approval has been seen. This is not a punishment. Rather, we care enough about you that we don’t want to see your teeth permanently disfigured from cavities. Perhaps you will be able to continue braces at a later date when you are able to take better care of your teeth and gums.

Additional note: Parents MUST play an active role in the oral hygiene of their children. When we issue oral hygiene warnings, parents all too often point at the child and state: “Did you hear what they just said?” It is important for parents to understand that dental health is a partnership between the patient, the office AND the parent. If your child is struggling with their home dental care, we will give you all of the tools to assist and supervise them so that they can see the end of treatment and a beautiful, cavity-free result. Failure do so has lifelong consequences.

I hereby grant permission to Shaw Orthodontics, its representatives and employees the right to take photographs of me and my property in communication with the above identified subject. I authorize Shaw Orthodontics, its assignees and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Shaw Orthodontics may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising and web content.

I also understand that once my image is posted on Shaw Orthodontics’ website, social media page(s), or online blog, any computer user, which is beyond the control of Shaw Orthodontics, can download the image and I will hold him/her and any of his/her affiliated offices harmless from any such use or download.

It is a general fact that the majority of patients in any orthodontic practice will be school age children and adolescents. It would make sense that with only a limited number of “after school appointments”, we SHARE the before school or after school appointment times among ALL of our patients. Please understand that it will be impossible to accommodate you or your child with a non-school time visit for EVERY appointment.

If it is absolutely necessary that you or your child must always have a before school or after school appointment time, we will happily accommodate you so long as you understand that it WILL LIKELY add treatment time to the overall orthodontic treatment plan. The fact that no orthodontic office can fit every student into the lesser number of non-school time appointments means that a later appointment will likely not be found at the time interval recommended by Dr. Shaw. So, if one needs to be scheduled 2 weeks later than desired because this is the only available non-school time appointment, two weeks has potentially just been added to treatment. Understanding that all parents face the same struggles with non school appointments will go a long way towards creating a fair system that will meet the needs of everyone most of the time.

Please also note that we perform certain longer appointments at times when Dr. Shaw can devote undivided attention without the before and after school “crush” of appointments. The following are some details regarding treatment in our office.

Normal Patient Treatment Office Hours: Tuesday-Thursday, 8AM-5PM

Typical Appointment Intervals to Our Office: Every 6-8 weeks, with the
understanding that from time to time we may need shorter intervals.

Braces Placement Appointments: Scheduled between 9AM-2PM because it requires precise attention at a less crowded time of day.

Removal of Braces Appointment: Scheduled on one specific day each month. We like to take the time and celebrate our patient’s getting their braces removed with a “Debond Party”.

Emergency Appointment Times: Are scheduled 8AM-4:30PM on Monday’s & Friday’s OR Tuesday-Thursday between 10AM-2PM so that attention may be given at a less crowded time of day.

By signing below, I am acknowledging that I have received this notice & understand that while Shaw Orthodontics will do its best to offer early or late appointments, I will be unable to have every orthodontic appointment before or after school.

By submitting this form, you agree to 1) all of the above forms and 2) that the information on this form has been explained to me and I fully understand that I am the only person who can accept responsibility for my retainer wear and maintaining my teeth in their current position.

I authorize the release to my insurance company or companies any information, including the diagnostic records and diagnosis of any treatment required to comply with applicable law and facilitate the billing and reimbursement for the treatment provided.

I, as the Responsible Party, acknowledge that a staff member has reviewed and all of my questions regarding the Office Policies & Financial Agreement. I certify that I have read, understand and do agree with the contents of this form.