CHILD START FORM.

Office policies & financial agreement.

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. 

1. 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.
2. 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. McMurphy or the staff). 
3. 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. McMurphy develops a custom treatment plan for each patient. For treatment to be as efficient as possible and to ensure the best possible result, Dr. McMurphy 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. McMurphy sees fit.
4. 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. McMurphy’s treatment recommendations may result in prolonged treatment time, compromised results, early removal of the braces and/or additional charges.
5. 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. McMurphy’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. This statement is meant for active treatment retainers and not those in the retention phase.
     1. 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. McMurphy’s sole discretion. If treatment is prolonged due to repeated replacements/repairs, you will be responsible for charges associated with the additional treatment time.
     2. Please see below the list of fees that will be charged accordingly.
        • $20 per broken bracket
        • If you don't have the extended retainer/whitening plan, replacement retainers are $200 each.
          
          • 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.
6. 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. McMurphy 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
7. Aligners: Excellent compliance with the aligner 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 aligner 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 aligner treatment Case Refinement.
   • The Midcourse Correction or the aligner treatment Case Refinement typically involve taking new scans of the teeth as well as updated photographs. A new series of aligners is then dispensed to the patient. 
8. 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:
   •  1.  Extended Retainer/Whitening Program. This program includes up to 4 sets of retainers per year for 6 years and 6 tubes of whitening gel for $599. 
   •  2.  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)
   • REPLACEMENT FEES for in house retainer program
     • $200 per replacement retainer without 3D printed model. 
     • Bonded retainer(s) (If Applicable) will be repaired at no charge if/when it breaks for the 1st time. If the bonded retainer(s) breaks after the 1st repair, the following fees, and conditions may apply:
       • $40 per pad repair fee, $280 for complete replacement of bonded retainer OR remove retainer(s), and switch to clear retainers.
         ***If the bonded retainer(s) breaks after the first repair, Dr. McMurphy may assess the pre-determined charge to repair the bonded retainer or decide to have a removable retainer made instead.
         ***It will be the patient’s responsibility to replace ill-fitting retainers that were not picked-up at the office as advised (the next day unless stated otherwise)
9. 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).
10. 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.
11. 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.
    • For various reasons, our 0% interest financing plans are required to be set up for auto-draft with both primary and secondary payment sources listed on the patient account.
    • LATE PAYMENTS. We understand life presents many challenges and we will do our very best to consider individual circumstances for each of our patients. However, we are unable to perform orthodontic treatment without the patient’s agreement and follow-through with payments for services rendered.
      • If a late payment surpasses 90 days the following two options must be considered:
        • removal of all orthodontic appliances and dismissal from the practice
        • a single $1000 deposit payment will be required to re-enter active treatment. This $1000 will be applied to your account and payments will then be continued at the agreed amount of your financing plan. (This means if you become over 90 days late in your payment agreement, you may finish your payment plan ahead of time due to the above policy.)
12. Transfers: While patients are discouraged to transfer during active treatment, we understand sometimes patients/families must move ( e.g. military patients). Transferring during treatment can potentially extend treatment time and increase your overall treatment fee. If the patient transfers 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:
    • This amount will be calculated based on:
      1. Initial down payment amounts. This amount varies according to your treatment type/plan and covers the higher initial costs for braces or aligners, materials, lab costs and time.
      2. Prorated by the number of months in treatment.
      3. Insurance coverage.
    • When a patient transfers, Dr. McMurphy will be happy to assist in finding you a new orthodontist in your new town who shares a like-minded treatment plan and uses similar braces/appliances/aligners so that your orthodontic treatment can be as seamless and efficient as possible.

You are always welcome to ask questions or discuss treatment progress with Dr. McMurphy. We want this to be an enjoyable experience, where you remain informed about your treatment progress and understand your role in helping us achieve our best results. We are thankful you chose us to be a part of your smile journey, and we are excited to discover the best parts about you. Then when we finish your awesome new smile, you’re going to want to show everyone else too.

Oral hygiene stoplight system.

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: “Do you hear what he 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 to do so has lifelong consequences.

Photo release form.

Subject: Social Media, Advertising, Educational Purposes, Illustrations, etc.

Location: McMurphy Orthodontics, Events Sponsored by McMurphy Orthodontics, etc.

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

I agree that McMurphy 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 McMurphy Orthodontics’ website, social media page(s), or online blog, any computer user, which is beyond the control of McMurphy 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. 

Acknowledgment of appointment times & agreement.

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. McMurphy. 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. McMurphy 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: Mon, Tue, Thu 8AM-5PM @ Biloxi. Wed and alternating Thu 7:30-4 @ Ocean Springs.

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

Retainer program options.

Did You Know?

If you don’t wear your retainer, your teeth will shift throughout your life? Wearing your retainer is an essential part to preserve your awesome new smile. Because we are committed to giving our patients amazing smiles that last a lifetime, we offer the following 2 Retainer Programs.

In-house Retainer Program (Treatment Plan)

• 3D Scan of Teeth

• 3D Printed Models of Both Upper and Lower Teeth

• 1 set of retainers (1 upper retainers and 1 lower retainers)

***At the day of braces removal additional sets of retainers can be purchased at half price ($100 per additional set).

Extended Retainer/Whitening Program

• This plan covers up to 4 sets of retainers per year for 6 years and 6 tubes of whitening gel.

Replacement Fees

• $200 per replacement retainer without 3D printed model. 

Bonded retainer(s) (If Applicable) will be repaired at no charge if/when it breaks for the 1st time. If the bonded retainer(s) breaks after the 1st repair, the following fees, and conditions may apply:

• $40 per pad repair fee, $280 for complete replacement of bonded retainer OR remove retainer(s), and switch to clear retainers.

***If the bonded retainer(s) breaks after the first repair, Dr. McMurphy may assess the pre-determined charge to repair the bonded retainer or decide to have a removable retainer made instead.

*** It will be the patient’s responsibility to replace ill-fitting retainers that were not picked-up at the office as advised (the next day unless stated otherwise)

The McMurphy Smile Guarantee.

McMurphy Orthodontics stands behind every patient’s smile, and wants to help every patient maintain that smile they worked so hard to achieve. If for any reason you experience any shifting, and become unhappy with the appearance of your teeth, don’t worry! We can fix it! We will put you back through treatment, and the only amount you pay is $189 per month for all of your adjustments, until you’re once again satisfied with your smile, and the cost of a new retainer to make sure you preserve that beautiful smile.