Dentsply Sirona Pty Ltd ABN 87 111 950 602 trading as SureSmile® SureSmile® Aligner Treatment Informed Consent Form

Congratulations on your decision to pursue orthodontic treatment for you or your child. SureSmile® clear aligners are an excellent choice made by your doctor to create beautiful, new smiles. Please read the following information and make sure that you ask any questions or raise any concerns you may have before signing the Informed Consent Form.

1. Failing to follow doctor instructions may interfere with achieving treatment objectives. This includes not wearing appliances as directed or missed appointments. All treatment times are estimated and may be extended by eruption of teeth or issues related to patient’s specific dentition, including uncommon tooth shape and any other anomaly encountered during treatment.
   
   
2. Inadequate patient oral hygiene during treatment may result in decay, gum irritation, tissue disease or permanent discoloration of teeth. In the event that all hygiene instructions are not followed, including regular brushing/flossing and regular practice of standard oral hygiene, intraoral inflammation or gum disease may result.
   
   
3. Minor discomfort when switching aligners during treatment is expected. However, any concern regarding pain or difficulty with placing a new appliance should be immediately reported to your doctor or staff. Patient may experience irritation to gums, cheeks or lips during treatment, which should also be communicated to doctor or staff. Allergic reactions are also possible and should be reported as well.
   
   
4. Interproximal (space between the teeth) re-contouring or minor shaping may be required to allow space for teeth to move for proper alignment.
   
   
5. Orthodontic treatment involves moving teeth and teeth may shift after treatment. Retainers must be worn at the direction of your doctor to control this tendency. In short, wearing retainers post-treatment is essential to maintaining your new smile.
   
   
6. In some cases, additional treatment appliances may be required for treatment plans. Such supplemental clinical requirements will be explained by your doctor. These may include the need for oral surgery to correct jaw position or severe crowding, which must be completed prior to aligner treatment.
   
   
7. Notify your doctor of any medical conditions/medications as they could affect treatment.
   
   
8. Dental implants cannot be moved by aligners. Additionally, existing restorations may require repositioning or replacement as the result of treatment, which may require additional dental, surgical or endodontic treatment. In extreme cases, teeth may be lost.
   
   
9. Orthodontic appliances can possibly be swallowed or aspirated. Any looseness of aligners or any other appliance used during treatment should be immediately reported to your doctor. In cases involving extreme crowding or missing teeth, product breakage is more common.
   
   
10. As is the case with any public health-care setting, it is possible that the doctor will not always be successful in preventing the transmission of a highly infectious virus. I assume the risk that I may be exposed to a communicable disease in the doctor’s office and/or by use of SureSmile® Aligner products.

Orthodontics is not an exact science, and I acknowledge that Dentsply Sirona Pty Ltd ABN 87 111 950 602 trading as SureSmile® and its subsidiaries (collectively, “SureSmile”) and my doctor have not and cannot make any guarantee or provide any other assurances regarding the outcome of any treatment. I understand that SureSmile is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give any medical advice. All clinical and treatment decisions made rest with my doctor.

In signing this Informed Consent Form, I am indicating that I understand the risks or options available for orthodontic treatment. Any concerns or questions that I may have had were sufficiently explained or answered by my doctor and I consent to treatment for myself.

I agree that my doctor may collect, hold and use my medical records, including but not limited to, x-rays, reports, charts, medical history, photographs, findings, dental plaster models or impressions, diagnosis, prescriptions, testing and results, billing or any other records regarding treatment and in my doctor’s possession relating to me (collectively “Records”). I agree that my doctor may disclose my Records to SureSmile, including but not limited to its employees or other representatives, successors, or assigns, and other licensed dentists or orthodontists if the Records are reasonably necessary for one or more of SureSmile’s functions or activities. Those functions and activities include treatment planning, training and support, marketing and advertising, and case study information for commercial and/or educational purposes. For more information on how SureSmile may handle your personal information, please see https://www.dentsplysirona.com/en-au/legal/privacy-policy.html 

To the extent permitted by law:

1. I will not, nor anyone acting on my behalf, seek legal, equitable or monetary damages or remedies for such use or disclosure;
   
   
2. I understand that no compensation will be provided for use and disclosure of my Records; and
   
   
3. I acknowledge that I as well as anyone on my behalf shall not have any claim or right to seek legal, equitable or monetary damages or remedies resulting from any use or disclosure permitted under the terms of this Informed Consent Form.
   
   

I confirm that I have read, understood and agree to terms stated in this Informed Consent Form as indicated my signature below. I agree that a fully executed and digitally scanned copy of this Informed Consent Form will constitute evidence of due execution and will have the same force and effect as an original.

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