Download 3. ADDITIONAL FEES 4. INSURANCE 5. PAST DUE

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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
A. Monthly payments are due on the 30th of each month. NO FINANCE CHARGE is made on
current accounts. However, if your account should become delinquent, there will be a $15.00 fee
added to your account on the 30th of the third month of which a payment is past due.
B. The above fee is for orthodontic services only. Monthly payments are merely a convenient method
of payment that assists some patients with particular financial needs. They do not represent the
work done in any particular month, since it is not unusual to see patients several times in one
month and not at all the next month. There is no relationship between the orthodontic fee and the
number or length of appointments.
C. Should your orthodontic work be completed prior to completion of payment; it is understood the
orthodontic fee will be paid in its entirety.
 THE BALANCE MUST BE PAID IN FULL BEFORE BRACES CAN BE REMOVED
3. ADDITIONAL FEES
This is a total fee for all orthodontic treatment outlined above and will remain the same except in the
following situations: poor cooperation from patient, which may result in additional treatment and
fees. Also, all appointments must be cancelled or rescheduled 24 hours prior to appointment time
or there will be a $50.00 fee added. If there is excessive breakage of orthodontic appliances (more
than 2 brackets, bands, or wires) there will be a $30.00 fee for each additional loose/ broken
appliance. This total fee also includes the cost of the retainer that will be worn after the braces are
removed. If an additional retainer is needed due to loss or breakage by the patient, a replacement
charge will be added. There will be an office charge for each additional visit after one year of
retention. There is also a $25.00 charge for all Non-Sufficient Fund checks.
The treatment fee does not include: Cleanings and examinations by your general dentist, fillings,
extractions, sealants, implants, jaw surgery, veneers, crowns, or other dental procedures.
4. INSURANCE
We will assist you with your orthodontic insurance; however, IF YOUR INSURANCE FAILS TO
MAKE PAYMENT, YOU WILL BE FULLY RESPONSIBLE FOR THE UNPAID
BALANCE.
5. PAST DUE
30 DAYS
60 DAYS
90 DAYS
Monthly payment is due in full by the end of each month
In the event that an account becomes 90 days delinquent, an auto late fee of $15.00 will be
added to the account, and the remaining balance must be paid to continue treatment. Your
treatment may be placed in a REST period, during which there is no tooth movement.
Appliances will be checked regularly (every 6-8 weeks), but lack of progress will lengthen the
treatment time. Your account will be turned over to a collection agency and/or an attorney.
You will be responsible for all legal and collection costs. If financial hardship occurs it is
the patient’s or parent’s responsibility to discuss the matter with the Financial Coordinator
immediately.
RESPONSIBLE PARTIES INITIALS:__________________
6. TRANSFER OR DISCONTINUATION
If you should move from within the area of our care, we will refer you to another orthodontist and
supply you with all your transfer records. If you transfer, you are responsible for all financial
arrangements with the new orthodontist, and we will assist you in any way we can. If the patient
transfers to another office or discontinues treatment, the financial contract may be adjusted. The
amount due for services rendered will be calculated by totaling the cost for records, appliance
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
construction, and treatment performed to date. Also, the patient and/or parent must be aware that Dr.
Hobson cannot influence the fees of the office which receives the patient in transfer. Frequently, both
the fee and the treatment time are increased by a transfer.
7. PATIENT COOPERATION
In order to achieve the best treatment results, it is expected that the patient will:
A. Follow instructions as to the care of the appliances.
B. KEEP ALL SCHEDULED APPOINTMENTS because missed appointments will lengthen
treatment time.
C. Brush teeth before each appointment to facilitate the adjustments and our office flow.
D. Wear additional appliances and elastics as prescribed.
E. Immediately inform our office should any part of the braces/appliances become loose, broken, of
damaged.
F. Have teeth cleaned and checked for cavities by the general dentist regularly, at least every six
months.
G. At the completion of treatment, x-rays, photos, and final study models will be required to
determine retainer needs.
H. After orthodontic appliances have been removed and retainers have been in place for one year,
the patient is placed on recall to maintain tooth position. There will be a charge for each visit.
I. Dr. Hobson cannot get good results or finish on time without 100% cooperation with regard to
headgear, elastic wear, and brushing. Dr. Hobson reserves the right to suspend treatment if the
patient does not cooperate, brush properly, or keep payments current.
8. INFORMED CONSENT AGREEMENT
The responsible party consents to orthodontic treatment recommended by Dr. Hobson. The treatment
plan has been fully explained to me by Dr. Hobson and his staff. I have read Dr. Hobson’s informed
consent form and I understand its content. I have discussed them with Dr. Hobson and his staff to my
satisfaction and I understand the potential risks and problems explained in the documents given to
me. It is understood that due to the heavy reliance on patient cooperation and favorable growth during
orthodontics, that as with any healing arts, ideal results cannot be guaranteed. I agree to allow the use
of x-rays, models, and pictures for case presentation and scientific purposes and I understand that
these records remain the property of Dr. Hobson. Further, I agree that the orthodontic fee will not be
included in any bankruptcy proceedings.
I have read and understand this agreement. I have discussed the risks of orthodontic treatment with Dr. Hobson to my satisfaction
and voluntarily agree to assume all risks of orthodontic treatment. I give my informed consent and I authorize Dr. Hobson, his
associates, assistants, and staff to perform orthodontic treatment as Dr. Hobson deems necessary. I also consent and agree to
assume all financial responsibility for orthodontic treatment.
Patient
Name_____________________________________
Guardian
Name_____________________________________
Witness
Name_____________________________________
Patient
Signature____________________________________
Guardian
Signature____________________________________
Witness
Signature____________________________________
DATE:____________________________
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
CONSENT FOR ORTHODONTIC TREATMENT
of_______________________________________________________Date________________________
Orthodontic treatment remains an elective procedure. It, like any other treatment of the body, has some inherent risks and
limitations. These seldom prevent treatment, but should be considered in making the decision to undergo treatment.
Results of Treatment
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the
best results for every patient. However, we cannot guarantee that you will be completely satisfied with your
results, nor can all complications or consequences be anticipated. The success of treatment depends on your
cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances,
and following the orthodontist’s instructions carefully.
Length of Treatment
The length of treatment depends on a number of issues, including the severity of the problem, the patient’s
growth and the level of patient cooperation. The actual treatment time is usually close to the estimated
treatment time, but treatment may be lengthened if, for example, unanticipated growth occurs, if there are
habits affecting the dentofacial structures, if periodontal or other dental problems occur, or if patient
cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If
treatment time is extended beyond the original estimate, additional fees may be assessed.
Discomfort
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the
introduction of orthodontic appliances. Non-prescription pain medication can be used during this
adjustment period.
Relapse
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life.
Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment.
You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular
retainer wear is often necessary for several years following orthodontic treatment. However, changes after
that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and
growth and maturation that continue throughout life. Later in life, most people will see their teeth shift.
Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may
require additional orthodontic treatment or, in some cases, surgery. Some situations may require nonremovable retainers or other dental appliances made by your family dentist.
Extractions
Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks
associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior
to the procedure.
Orthognathic Surgery
Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction
with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you
should discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please
be aware that orthodontic treatment prior to orthognathic surgery often aligns the teeth within the individual
dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned
surgical procedures may have a malocclusion that is worse than when they began treatment!
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
Decalcification and Dental Caries
Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist.
Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the
benefit of fluoridated water or its substitute, or if the patient often consumes sweetened beverages or foods.
Root Resorption
The roots of some patient’s teeth become shorter (resorption) during orthodontic treatment. It is not known
exactly what causes root resorption, nor is it possible to predict which patients will experience it. However,
many patients have retained teeth throughout life with severely shortened roots. If resorption is detected
during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the
appliances prior to the completion of orthodontic treatment.
Nerve Damage
A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve
of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root
canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.
Periodontal Disease
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors,
but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a
periodontist monitor your periodontal health during orthodontic treatment every three to six months. If
periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to
completion.
Injury from Orthodontic Appliances
Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. This
can result in orthodontic appliances being inhaled or swallowed by the patient. You should inform your
orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed.
Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when
orthodontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored)
appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved
tooth/teeth by your dentist may be necessary.
Headgears
Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes.
Patients must remove the elastic force prior to removing the headgear from the mouth so that it does not
spring back. Refrain from wearing headgear in situations where there may be a chance that it could be
dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.
Temporomandibular (Jaw) Joint Dysfunction
Problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches or ear
problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or
face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly
balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic
treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or closing, should be
promptly reported to the orthodontist. Treatment by other medical or dental specialist may be necessary.
Impacted, Ankylosed, Unerupted Teeth
Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to
erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated.
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
Treatment of these conditions depends on the particular circumstance and the overall importance of the
involved tooth, and may require extraction, surgical exposure, surgical transplantation or prosthetic
replacement.
Occlusal Adjustment
You can expect minimal imperfections in the way your teeth meet following the end of treatment. An
occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the
occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby
“flattening” surfaces in order to reduce the possibility of relapse.
Non-Ideal Results
Due to the wide variation in the size and shape of the teeth, missing teeth, etc., achievement of an ideal result
(for example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic
bonding, crowns, bridges or periodontal therapy, may be indicated. You are encouraged to ask your
orthodontist and family dentist about adjunctive care.
Third Molars
As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist
should monitor them in order to determine when and if the third molars need to be removed.
Allergies
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances.
This may require a change in treatment plan or discontinuance of treatment prior to completion. Although
very uncommon, medical management of dental material allergies may be necessary.
General Health Problems
General health problems such as bone, blood or endocrine disorders, and many prescription and nonprescription drugs can affect your orthodontic treatment. It is imperative that you inform your orthodontist of
any changes in your general health status.
Use of Tobacco Products
Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing
after oral surgery. Tobacco users are also more prone to oral cancers, gum recession, and delayed tooth
movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a
compromised orthodontic result.
If any of the complications mentioned above do occur, a referral may be necessary to your family dentist
or another dental or medical specialist for treatment. Fees for these services are not included in the cost
for orthodontic treatment.
ACKNOWLEDGEMENT
I hereby acknowledge that I have read and full understand the treatment consideration and risks presented in
this form. I also understand that there may be other problems that occur less frequently than those presented,
and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this
form with the undersigned orthodontist and have been given the opportunity to ask any questions. I have
been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize
the orthodontist indicated below to provide the treatment. I also authorize the orthodontist to provide my
health care information to my other health care providers. I understand that my treatment fee covers only
treatment provided by the orthodontist, and that treatment provided by other dental or medical professionals
is not included in the fee for my orthodontic treatment.
Patient or Parent/Guardian Initials____________
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
CONSENT TO UNDERGO ORTHODONTIC TREATMENT
I hereby consent to the making of diagnostic records, including x-rays, before, during and following
orthodontic treatment, and to the above doctor(s) and, where appropriate, staff providing orthodontic
treatment described by the above doctor(s) for the above individual. I fully understand all of the risks and
limitations associated with the treatment.
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
I hereby authorize the above doctor to provide other health care providers with information regarding the
above individual’s orthodontic care as deemed appropriate. I understand that once released, the above
doctor(s) and staff has (have) no responsibility for any further release by the individual receiving this
information.
_________________________________________________________
Signature of Patient/Parent/Guardian
Date
_________________________________________________________
Signature of Orthodontist
Date
_________________________________________________________
Witness
Date
CONSENT TO USE OF RECORDS
I hereby give my permission for the perpetual use of orthodontic records, including photographs, made in the
process of examinations, treatment, deband, retention, and social events attended for purposed of professional
consultations, research, education, or publication in professional journals and the social media that is connected
with Dr. David C. Hobson’s office ( Facebook, YouTube, Twitter, etc.).
_________________________________________________________
Signature
Date
_________________________________________________________
Witness
Date
I have legal authority to sign this on behalf of
_________________________________________________________
Name of Patient
_________________________________________________________
Relationship of Patient
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David C. Hobson, D.D.S., M.S., PC
114 Minnie Street, Suite B
Fairbanks, AK 99701
APPOINTMENT SCHEDULING
Our goal is to be the best part of your day. We make it a top priority to value both you and your time. That’s why we make every
effort to stay on or ahead of schedule. However, it is unavoidable that some work-time/ school-time appointments will be
necessary. To ensure quality orthodontic care, it is important that our patients understand the manner in which we schedule.
We will be glad to work around schedules as often as possible. We can provide the receipts or proof of orthodontic appointments
for submission to your school or work. We want you to know that our staff will work hard to provide the finest orthodontic care
with the most convenient scheduling system possible.
 Long appointments, Initial records for fabrication of appliances, Bonding and Banding
appointments: These are more detailed and technique-sensitive appointments. Therefore,
these appointments will be scheduled during our quieter hours.
 Emergencies: (discomfort, swelling, or bleeding) This usually results from trauma to the face
or mouth. These patients will be seen as soon as possible and appropriate care given or
referred to another specialist for treatment.
 Repairs: (loss or breakage of appliances) These appointments are always scheduled during
our quieter hours at a specific time because they are long visits. There is a $30.00 fee for each
broken/lost bracket (after the first month). The vast majority of your appointments over the
course of treatment will be short appointments. By seeing our long-visit patients during
work/school hours, we can accommodate more people in our schedule at those busy times.
 Appointments: Your treatment indicated that you be seen by Dr. Hobson at specific intervals.
Your office visits will be scheduled approximately every 6-8 weeks for full treatment and 810 weeks for limited/appliance treatment to monitor your progress.
 Appointments broken or not cancelled within 24 Hours: There will be a charge for no
show appointments. Another appointment will be scheduled but may require waiting 2-4
weeks. An appointment during school/work hours may be arranged sooner.
Patient Signature:___________________________________
Date:________________
Guardian Signature:_________________________________
Date:________________
Dear Parents and Patients:
We would like to take this opportunity to share some information with you regarding tooth
DECALCIFICATION.
DECALCIFICATION MEANS PERMANENT WHITE SCARS THAT CAN BE ETCHED
INTO THE TOOTH ENAMEL WITH IMPROPER HOME CARE. This is all too common with teeth
that have “braces”, but can be prevented by you! Decalcification cannot be seen until the actual etching has
occurred, and by then it is TOO LATE.
It is absolutely mandatory to brush at least three times per day (after everything you eat would be
best) and use your fluoride daily. Research on patients with braces shows that daily use of fluoride
eliminated decalcification. Brushing is still needed after drinking anything other than water. Sugar and other
food particles tend to sit along the gum line. The brackets/braces act as a shelf, allowing the build-up of
plaque, which also will cause decalcification. Onset of this problem can be quite rapid!
We appreciate your help and support in this area. We want you to have the most beautiful results
possible, and not be disappointed when your braces come off by having these permanent white
decalcification marks on your teeth.
Please take this very seriously,
Dr. Hobson and Staff