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DENTAL AND ORTHODONTIC HISTORY

Informed Consent in Orthodontics

DEAR PARENT/PATIENT:

As a rule, an informed and cooperative patient can achieve excellent orthodontics results. Thus, the following information is routinely supplied to anyone considering orthodontic treatment in our office. While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has inherent risks and limitations. These are seldom enough to contradict treatment but should be considered in deciding to wear orthodontic appliances.

Perfection is our goal. However, in dealing with human beings and growth and development problems, genetics, and patient cooperation, achieving perfection is not always possible. Often a functionally and esthetically adequate result must be accepted.

Throughout life, tooth position is constantly changing. This is true with individuals regardless of whether they have had orthodontic treatment or not. Post-orthodontic patients are subject to the same subtle changes that occur in non-orthodontic patients. We recommend that you always keep your retainers to maintain our achieved orthodon- tic results.

Decalcification (permanent marketing), decay, or gum disease can occur if patients do not brush their teeth thor- oughly and adequately during treatment. Excellent oral hygiene and plaque removal are a must. Sugars and between meal snacks should be minimized.

On rare occasions, the nerve of a tooth may become non-vital. A tooth traumatized from a deep filling or even a minor blow can die over a long period with or without orthodontic treatment. An undetected non-vital tooth may flare up during orthodontic movement requiring endodontic (root canal) treatment to maintain it.

In some cases, the root ends of the teeth are shortened during treatment. This is called resorption. Under healthy circumstances, the shortened roots are at no disadvantage. However, in the event of gum disease later in life, root resorption could reduce the longevity of the affected teeth. Patients should note that not all root resorption arises from orthodontic treatment. Trauma, cuts, impactions, endocrine disorders, or idiopathic reasons can cause root resorption.

There is also a risk that problems may occur in the temporomandibular joints (TMJ Although this is rare, it is possible. Tooth alignment or bite correction can improve tooth-related causes of TMJ pain but not in all cases. Tension appears to play a role in the frequency and severity of joint pain.

Patients must follow headgear instructions carefully. A headgear pulled outward while elastic force is attached can snap back and poke into the face or eyes. Be sure to release the elastic pressure before removing the headgear.

The total time for treatment can be delayed beyond our estimate. Disproportionate facial growth, atypical formation of teeth, poor elastic wear or headgear cooperation, broken appliances, and missed appointments are all important factors that can lengthen the treatment time and affect the quality of the result.

Damage to a tooth's enamel or to a restoration (crown, bonding, veneer, etc is possible when orthodontic appliances are removed. If damage to a tooth or restoration occurs, treatment by your general dentist may be necessary.

I have read and fully understand the above.

General Consent and Practice Policy

The doctors and staff at this practice are committed to our patient’s superior oral health. We follow scientific and ethicalprinciples in order to provide our patients with the highest standard of orthodontic care. We try to create a fun, friendly andcomfortable environment and we work hard to keep overall treatment length and appointment times to an absolute minimum.We know you have a choice in orthodontic providers and we hope that these goals are the primary reasons you have chosenour practice. The following practice policies help reinforce these guiding principles.

• Payment/Insurance Policy: Unless other payment options are arranged through a signed contract with the office, payment in full isdue at the time of service. We accept all major credit cards, cash, or personal checks. We cannot guarantee any estimated coveragewhen billing insurance. Patients are responsible for determining if their insurance is contracted for the services that will be provided.Patients are responsible for any remaining balance not paid by insurance. There will be a $50 service fee on any returned checks. Allunpaid balances are subject to a 10% processing fee and may incur a 1.5% monthly finance charge. All delinquent balances must bepaid prior to incurring any new charges. Any service overpaid will automatically be refunded to the patient’s original payment methodwithin 60 days. Checks will be issued within 60 days from the payment date for patients who made a cash payment.
• Missed or Canceled Appointment Policy: Due to the busy nature of our practice and as a courtesy to the doctors and staff who areproviding care, we ask that you please make your appointments a top priority. If you are unable to make the scheduled appointment,please give us sufficient notice to be able to fill the appointment slot. We ask that you call to reschedule or cancel at least 24 hours inadvance. If you miss or break your appointment with less than 24 hours notice, you may be subject to a cancellation fee up to $100.A second last minute cancellation or no-show may lead to the end of the doctor-patient relationship.
• Late Appointment Policy: We ask that patients be on time for all scheduled appointments in order to fully utilize their appointmenttime and minimize the impact to other patients scheduled that day. If a patient is more than 10 minutes late to an appointment theymay be required to reschedule or asked to wait until after the on-time patients have been seen. Regular tardiness may lead to the endof the doctor-patient relationship.
• Consent to Treat Policy: I give permission for the practice to perform orthodontic procedures within the scope of dentistry asdeemed necessary. I acknowledge that every orthodontic case is unique and understand that occasional adjustments to the originaltreatment plan may be necessary to achieve the best result. I authorize the provider to use their professional judgment for proceduresin addition to or different from those originally contemplated. I have provided as accurate and complete medical history as possibleincluding those antibiotics, drugs, medications, and foods to which my child is allergic.

• Communication Policy: Our top priority is to give you all the information needed to make informed decisions in regards to youryour childs oral health This includes providing you with recommended procedures the risks of those procedures any treatment alterna tives and an estimate of the costs involved to perform those procedures If you have any concerns about our treatment or policies please bring them immediately to our attention SO that we can resolve any questions and continue to develop a longterm relation ship where youryour childs oral health and dental experience is number one for both of us
• Communication from Bluetree Brands: I give my consent to receive relevant communication from Bluetree brands (parent company) and its affiliated partners.
• Social Media/Image Consent: I give consent to use images taken of memy child to showcase the extraordinary care we have received

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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