clearcareperio.com - Informed consent for placement of Temporary Anchorage Device (TAD)

Informed consent for placement of Temporary Anchorage Device (TAD)
Name of the patient*

First NameLast Name
I accept for myself (or on behalf of my dependent) proposed treatment by Dr. which includes the use of TADs (mini screws) to help with positioning of teeth.
I understand that TADs will be used as an anchor to help stabilize, or for movement of a tooth or group of teeth. It was explained to me that TADs will be inserted into my palate, behind my last tooth or into the space between upper and lower teeth.

It was explained to me that the TADs will be inserted with the aid of the local anesthetic. The insertion procedure was explained to me thoroughly and I understand that the absolute success of all TADs cannot be guaranteed.

Some complications may occur:
1. Discomfort, mild pain and swelling in the area
2. Inflammation or infection of the insertion site
3. Mobility or loss of TAD
4. Penetration of TAD to the maxillary sinus*
5. Injury of the nerve
6. Fracture of TAD
7. Damage of the dental roots or adjacent structures
*Only if TAD is placed in the maxilla
I understand the content of this informed consent. I had the opportunity to ask questions and all of my questions were answered.
Signature - patient or parent/guardian*

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Printed name - patient or parent/guardian*

First NameLast Name
Date*

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Date
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