Download Orthodontic treatment information and consent

INFORMED
INFORMED CONSENT
FOR ORTHODONTIC TREATMENT
Your/Your son/daughter's orthodontic treatment will improve the position of your/their teeth and/or jaws. This is
aimed at producing a cosmetic benefit, and may also improve other aspects of future dental health. However,
the treatment is complex, and not completely without risk. This sheet outlines the risks and responsibilities, and will be
stored with your orthodontic notes as a record of the fact that such risks have been discussed with you. It must be
stressed that significant problems are very rare providing the brace is cared for properly.
What result can I expect from the treatment?
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results
for every patient. Our results are usually excellent and it is extremely rare for anyone not to be happy with the results of
treatment. Unforeseen factors, nevertheless, may interfere with our expectations. Therefore, we cannot guarantee that
you will be completely satisfied with your results, nor can all complications or consequences be anticipated. As treatment
proceeds we will keep you informed of the treatment progress and of any situation that may arise. If your original goals
become unobtainable, we will discuss the alternatives with you and your dentist. The success and length of treatment
depends largely on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken
appliances, and following the orthodontist's instructions carefully (e.g. wearing elastic bands / removable appliances /
retainers / aligners). Different biological factors such as bone density and the rate of growth differ between patients and
is very hard to anticipate. Unexpected or slower than normal tooth movements and growth can increase the length of
treatment or affect the final results. These factors depend on age, maturity and hormonal differences and are out of our
control. In rare occasions, 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
aesthetic bonding, crowns or bridges or periodontal therapy, may be indicated. You are encouraged to ask your
orthodontist and general dentist about adjunctive care.
Retention: Will my teeth stay in their treated position?
Your mouth changes shape throughout life. For this reason, it is likely that once you stop wearing your retainer, your
teeth will move. This is particularly common with the lower front teeth, and any teeth that were severely twisted before
treatment. Every effort will have been made when planning treatment to minimise the chance of significant movement,
and even in the long-term, your teeth are likely to remain in a better position compared to that before treatment. In order
to be sure that your teeth do not move, it will be necessary to wear your removable retainers as instructed by your
orthodontist on a long-term basis and on alternate nights indefinitely, and/or to have a fixed retainer bonded to the back
of the teeth and use a removable retainer on top over your teeth on alternate nights indefinitely. Other types of retainers
may be advised. Even following a period of retention, some change may occur. Changes in tooth position are not a failure
of your orthodontic treatment but are a natural process. These changes are minimised by retainer wear. However, if
significant adverse tooth movement occurs (relapse), this may require additional orthodontic treatment or, in extreme
cases, surgery.
How long will my treatment take?
The length of treatment depends on a number of issues, including the severity of the problem, the patient's age, growth
and the level of patient cooperation. Because individuals vary considerably in their response to orthodontic treatment,
the actual treatment time, although usually close to the estimate that the orthodontist can give you, can be more or less
than our estimated treatment time. The treatment may be lengthened if, for example, unanticipated growth occurs, if
there are habits affecting the dento-facial structures, if periodontal or other dental problems occur, if patient cooperation
is not adequate, if the oral hygiene is poor, or by appliance loss or breakages and missed appointments. This may also
affect the quality of the end result. Therefore, changes in the original treatment plan may become necessary. Following
treatment, there will be a period where "retaining" braces will need to be worn to allow the teeth to stabilise in their new
positions. (See: Retention)
Is wearing braces uncomfortable?
Everyone's experience is different, but in general, for the first one to two weeks after fitting the brace, your teeth will be
tender and may ache, and you will not be able to chew tough foods. Your cheeks, lips and gum may become sore, and you
may get ulcers in your mouth. These problems can usually be controlled and the orthodontist will advise you how to
reduce the discomfort. Severe discomfort is very rare, but can only be remedied by removing the brace and abandoning
treatment. Each time the brace is adjusted, your teeth may again ache for a few days. Some types of braces may
temporarily affect your speech and may result in a lisp until you get used to them. Some may result in temporarily
increased salivation or a dry mouth, certain medical drugs may increase this effect.
Risks: Are there any risks with
with orthodontic treatment?
Adverse effects may occur as a result of orthodontic treatment, even if treatment is carried out competently. It is important
to note that it is not possible to list every circumstance, so the following list is extensive but incomplete.
Commonly
Commonly occurring adverse effects
1) Demineralisation
caries:: Failure to keep the brace clean and to avoid sugary or acidic food and drink will
Demineralisation and caries
lead to decay/cavities, discoloured teeth and decalcification/white spots occurring around the brace. This will often not
be detectable until the brace is removed, and by then it can be severe and cause significant cosmetic and dental health
problems.
2) Periodontal (gum and bone) problems:
problems Virtually all patients will experience some gingival (gum)
inflammation when fixed appliances are worn. However, these changes are usually reversible and resolve once the
appliances are removed. Poor oral hygiene can cause irreversible gingival or periodontal damage. If this 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.
In the case of adults with pre-existing periodontal problems, the primary aim before orthodontic intervention is to
control and stabilise the periodontal condition. There is good evidence that provided high quality periodontal
intervention and regular maintenance is carried out and the patient is able to maintain adequate hygiene procedures to
control the disease, even in the presence of previous alveolar bone loss, then fixed appliance treatment can be carried
out safely and satisfactorily. Regular hygienist appointments and periodontal maintenance care while wearing fixed
appliances is mandatory in adult patients. A follow-up X-ray may be taken during treatment. If a problem 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.
3) Idiopathic inflammatory root resorption is an unavoidable consequence of orthodontic tooth movement. The
roots of your teeth may shorten very slightly during treatment with fixed appliances i.e. 1-2 mm. This causes no long-term
problems in an otherwise healthy mouth. A small degree of tooth mobility is normal during treatment.
4) Discomfort/pain
Discomfort/pain after placement or adjustment of orthodontic appliances are commonly reported by patients.
(See: Is wearing braces uncomfortable?)
5) Relapse:
Relapse some tooth movement always occurs after orthodontic treatment. This is very important to understand
before treatment starts. The extent of tooth movement after treatment is partly dependant on pre-treatment tooth position.
Gaps, rotations and overbite have a high potential for relapse. Long-term or permanent retention is planned and it is
important to follow the retention instructions as prescribed (See: Retention).
Less common
common adverse effects
1) Extensive root resorption
resorption:: Very rarely, movement of teeth results in the roots being damaged/ shortened
extensively which may affect the health of the teeth. It is not known exactly what causes root resorption, nor is it possible
to predict which patients will experience it. Some evidence suggests that patients whose teeth have abnormal root form,
short roots with blunt ends, previously damaged or traumatised teeth have an increased risk. It is therefore very important
to tell us if you have ever received a blow to your teeth, whether or not this caused obvious damage. There is also
evidence that treatment-related root resorption is correlated with the distance the tooth moves and the length of
treatment. However, extensive resorption can occur unexpectedly due to unpredictable individual susceptibility. A followup X-ray may be taken during treatment. 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. These
teeth may require root-filling. However, many patients have retained teeth throughout life with severely shortened roots.
2) Dental, restorative
restorative and tooth nerve damage
damage: Some degree of tooth nerve inflammation can be expected
during orthodontic tooth movement. In general such changes are reversible and cause no long-term problems. For teeth
that have previously been traumatised or extensively restored teeth, the blood supply may already be compromised with a
consequently greater risk of tooth nerve damage and loss of vitality. These rare cases may require root treatment, further
dental treatment or restoration. Enamel erosion and wear is a risk that is more common in patients who grind the teeth, or
may be associated with teeth that have undetected fracture lines and defects within it. In other instances, existing tooth
restorations (e.g. Crowns, veneers…etc) might loosen and may have to be re-cemented or even replaced.
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3) Injury from Orthodontic appliances:
appliances Orthodontic appliances, especially when loosened or damaged, can be
accidentally inhaled or swallowed or could cause other damage to the patient. 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 clear fixed appliances have been selected. If damage to a tooth or restoration occurs, restoration of the
involved tooth/teeth by your dentist may be necessary.
4) Temporomandibular joint (Jaw Joint)
Joint) problems:
problems symptoms include pain, limited mouth movement, jaw noise,
headaches or ear ringing. 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 which may be related to
stress and emotional factors, depressive illness, sleep disorders, poorly balanced bite and many medical conditions. But for
most jaw joint problems, scientists don’t know the cause. For many people, symptoms seem to start without an obvious
reason. Research disputes the popular belief that an uneven bite can trigger TMJ disorders. Because the condition is more
common in women than in men, scientists are now exploring a possible link between female hormones and TMJ disorders.
Therefore, jaw joint problems may occur with or without orthodontic treatment. Any jaw joint symptoms should be
promptly reported to us. Treatment by other medical or dental specialists may be necessary. It is important to understand
that current scientific evidence does not recommended using orthodontic treatment as a way of treating or preventing jaw
joint problems. At the same time, current evidence suggests that orthodontic treatment does not cause jaw joint problems.
5) Impacted, Ankylosed, Unerupted Teeth:
Teeth Teeth may become impacted (trapped below the bone or gums),
ankylosed (fused to the bone) or just fail to erupt. On the rare occasions when they do occur, it is usually for no apparent
reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circumstance and
the overall importance of the involved tooth, and may require change in the treatment plan, extraction or surgical
exposure.
6) Occlusal
Occlusal adjustment:
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.
7) Allergies, mouth disease and general
general health problems:
problems 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 such as bone, blood or endocrine disorders, and many prescription and nonprescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that you inform
your orthodontist of any changes in your general health status.
8) Use of tobacco:
tobacco If you use tobacco, you must carefully consider the possibility of a compromised orthodontic
result as tobacco reduces the blood flow to the tissues of the mouth, at a time when good blood flow is needed for tooth
movement. Tobacco users are also at a greater risk of oral cancer, periodontal disease, gum recession and delayed tooth
movement during orthodontic treatment. We recommend all tobacco users to cease the practice of tobacco use and seek
advice from their dentist or general medical practitioner (GP).
Responsibilities: What are my responsibilities?
The orthodontist is not responsible for your general
general dental health. It is important that you continue to see your general
dentist for regular checkcheck-ups, and preferably arrange to see a hygienist at 3 monthly intervals.
1) Tooth brushing:
brushing The brace will require cleaning after every intake of food. This will require much more effort
than normal tooth brushing and you should be sure of cleaning every part of it. If a removable appliance is worn, this
should be removed for cleaning the teeth and appliance and replaced straight away. Using a Fluoride mouthwash during
treatment will help maintain healthy teeth. If you find difficulty with this, you should ask the orthodontist or your dentist /
hygienist for advice.
2) Eating and other habits: You must be careful when eating to ensure that the brace is not broken. You must
avoid all hard, sticky, chewy, crunchy foods as these can damage the appliances and bend the wires, thus stopping tooth
movement. You must avoid food and drink high in sugar content as these can lead to tooth decay and permanent marks
on the teeth. You must avoid fizzy drinks and fruit juices as these are acidic and may cause permanent marks on the teeth.
You must also avoid habits such as nail biting, pen chewing, or opening bottles with your teeth! Thumb or finger sucking
will also interfere negatively with the orthodontic treatment.
3) Breakages: Once a brace/appliance/retainer is broken, the teeth drift back to their "starting positions" very
quickly. As a result, any breakages must be reported to us as a matter of urgency. There may be a charge for this according
to the breakage and the type of brace/appliance/retainer. You must check the brace/appliance/retainer daily for any
broken or loose components. If you notice anything wrong, you should telephone and request an urgent appointment
even if you already have a scheduled appointment booked. If the brace/appliance/retainer is not repaired quickly, it will
result in a longer treatment time or may require re-treatment, and may even do harm to your teeth or gums, unless the
orthodontist advises otherwise. We are not financially responsible for replacements or repairs to appliances or retainers.
Repairs to broken fixed appliances after the third breakage will incur a charge as per our menu of services. Multiple
repeated breakages may result in terminating your treatment before being completed, as repeated breakages increase the
risk and time of treatment beyond acceptable levels, making the risks of orthodontic treatment outweigh the benefits.
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4) Failure to attend:
attend Failure to attend an appointment without giving us at least 24 hours notice will incur a charge
as per our menu of services. Repeated failure to attend appointments may result in the treatment being terminated before
being completed.
5) Adjustments:
Adjustments You will need to attend regularly every 4 to 12 weeks (depending on the treatment stage) to have
your appliance adjusted. Missed appointments are very disruptive to orthodontic treatment, and you may wait a long time
to get a new replacement appointment. If your brace has not been adjusted for longer than 14 weeks, you must contact us
as you may have missed an appointment and not realised.
6) Elastic bands:
bands You may be asked to wear elastic bands to help tooth movement. Failure to wear them or
wearing them incorrectly can prolong your treatment or affect the result.
Enamel Stripping (Inter(Inter-proximal reduction – IPR)
Enamel reduction or slenderizing is a procedure to remove a slight amount (0.1 to 0.5mm) of enamel between the teeth to
create space for the correction of crowded teeth or to enable the teeth in each jaw to come together more efficiently. The
enamel is removed with a high-speed rotary instrument or by manual strips. It does not require anaesthetic and is a safe
procedure that will not lead to increased risk of tooth decay or gum disease. It does not harm your teeth although a side
effect can be temporary tooth sensitivity to hot or cold which can be easily overcome by using Fluoride mouthwash and
toothpaste. If you feel sensitivity, it usually lasts for a day or a few days.
Using aligners / positioners
positioners
Commitment: This treatment will only succeed if you fully comply with the orthodontist’s instructions. You must make sure
that any dental work that will alter the shape or size of your teeth is completed before the impressions are taken and the
positioners are made. You receive a set of aligners for each treatment stage, the total number of aligners and treatment
duration depends on the complexity of your orthodontic problem. The aligners will be individually numbered and will be
dispensed to you by your orthodontist with specific instructions for use. You must wear the aligners at least 20 hours per
day in total for them to be effective (ideally 20 to 22 hours a day), following the specific instructions for night aligners and
day aligners as explained by your orthodontist. Each set of aligners should be worn for at least 3 weeks (the orthodontist
may have you use them longer) and then returned to your orthodontist as you may need to use them again if required. It is
important to attend your follow-up appointments regularly to monitor the treatment progress, normally every 6 to 8 weeks.
The aligners should be removed when eating, drinking (anything other than water), cleaning your teeth and playing contact
sports, during which they can be stored in a hard case. Clean the aligners with a wet gentle toothbrush and rinse them with
COLD water. Do not use toothpaste or any abrasive material to clean the aligners. Compatible cleaning products can be
used.
Limitations:
Limitations Treatment with aligners / positioners is not suitable for all types of orthodontic problems. Your orthodontist will
advise you if your case is eligible to be treated with aligners or if there are more efficient alternatives to achieve a better
result. A lack of compliance, failure to wear the appliances for the required number of hours per day, not using the product
as instructed, missing appointments and atypically shaped teeth can lengthen the treatment time and affect the quality of
the end result or the possibility of achieving the desired result. Teeth that are not at least partially covered by the aligner
may undergo supraeruption. Short clinical crowns can pose aligner retention issues and inhibit tooth movement. Some
patients may require additional refinement at the end of the aligner treatment to achieve the intended treatment goal. A lot
of care is required with these aligners as they are fragile and may break. Please be aware that the breakage or a loss of an
aligner could prevent your treatment from being completed if not replaced or worn as instructed.
Replacement of broken or lost aligners will incur an additional charge to the patient. If the patient fails to wear the aligners
as instructed, then new aligners would have to be manufactured to achieve the desired result, this will incur an additional
charge to the patient.
Teeth may shift position after treatment, life-long retention is essential to prevent relapse (See: Retention).
Risks:
isks: All the risks and responsibilities explained in the previous paragraphs for other types of orthodontic appliances apply
to treatment with aligners / positioners, so read them carefully (See: Risks) (See: Responsibilities)
It is normal to feel pressure and dental tenderness after switching to the next aligner in the set. It takes a couple of days to
get used to the aligner. Gums, cheeks and lips may be slightly irritated or scratched. Speech may temporarily be affected
and may result in a lisp until you get used to them, this should disappear within one or two weeks. The use of aligners may
result in temporarily increased salivation or a dry mouth, certain medical drugs may increase this effect. It may be necessary
to reduce the enamel of some teeth to create some space for tooth movement (See: Enamel Stripping). Some patients
require bonded attachments (small aesthetic tooth-coloured dental composites bonded or glued to the front or back side of
specific teeth) and/or elastics on their teeth to facilitate specific dental movements. Aligners are designed to have
maximum strength and minimum injury potential, however they may accidentally break and in rare occasions cause injury
and /or swallowing / inhalation of the broken parts or loose attachments.
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Temporary Anchorage Devices (Micro(Micro-implants)
Your treatment may include the use of a temporary anchorage device(s) (i.e. metal screw or plate attached to the bone)
which is rigidly placed in the upper or lower jaw bone for use as an anchor in the mouth that can be used immediately after
placement. Its placement is a minimally invasive surgical procedure which diminishes the trauma and post-operative
discomfort associated with traditional dental implants. However, there are specific risks associated with these microimplants.
It is important to understand that anchorage control is the primary goal of this orthodontic procedure, but that success rates
vary for each patient. No guarantees of success can be given. The use of tobacco, including cigarette smoking as well as
excessive alcohol consumption, or altered sugar metabolism can effect bone/gum healing and may cause failure of the
micro-implant.
The procedure itself may lead to slow oozing of blood for 12-24 hours after surgery. Some situations, such as taking aspirin,
can result in longer periods of oozing. Infection and/or pain may be rarely associated with this procedure.
It is possible that the screw(s) could become loose which would require their removal and possibly relocation or
replacement with a larger screw. The screw and related material may be accidentally swallowed. If the device cannot be
stabilized for an adequate length of time, an alternate treatment plan may be necessary.
It is possible that the tissue around the device could become inflamed or infected, or the soft tissue could grow over the
device, which could also require removal, surgical excision of the tissue and/or the use of antibiotics or antimicrobial rinses.
It is possible that the screws could break (i.e. upon insertion or removal). If this occurs, the broken piece may be left in your
mouth or may be surgically removed. This may require referral to an oral surgeon.
When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually
these problems are not significant; however, additional dental or medical treatment may be necessary. In extremely rare
occasions, temporary or permanent numbness occurs to the lips, gums, tongue, chin, jaw or other teeth due to nerve
damage. Very rarely, when the teeth are jammed so lightly against adjacent teeth, implant placement in these locations can
cause damage to the crowns or roots of these teeth, which could require the replacement of a crown, a root canal, or
extraction of the tooth with replacement by a bridge or an implant/crown.
Local anaesthetic may be used when these devices are inserted or removed, which also has risks. Please advise us if you
have had any difficulties with dental anaesthetic in the past. If you know of any past allergies, are taking any drugs you
haven't told us about, or have any major illness you failed to write down, it is important to let us know.
If any of the complications mentioned above do occur, a referral may be necessary to your dentist or an oral surgeon or
medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.
Oral surgery
Tooth removal (Extractions) or jaw surgery (Orthognathic surgery) is sometimes necessary in conjunction with orthodontic
treatment to correct crowding or severe jaw imbalances. These procedure will be recommended by the orthodontist if it
improves the prospects for successful treatment. The additional risks involved with the surgery, anaesthesia and proper
healing should be discussed with the dentist / oral surgeon before making a decision to undertake the procedure.
Discontinuation of Treatment
By the Orthodontist: Failure to keep orthodontic appointments, to look after your brace with respect to cleaning or
breakages, poor cooperation or failure to follow treatment instructions may result in a verbal warning of treatment being
discontinued. If the situation does not improve, it may then result in the treatment being terminated before being
completed. The orthodontist will discuss this with you beforehand if it becomes evident that these shortcomings are
increasing the risk and time of treatment beyond acceptable levels, making the risks of orthodontic treatment outweigh
the benefits.
By the patient: The orthodontist will recommend keeping the brace until your treatment is finished and all the
treatment goals are achieved to reduce the risk of relapse after the brace is removed. Tightening the brace more often or
tighter will NOT make the treatment go faster. In rare circumstances, the patient may want to discontinue the treatment
despite the orthodontist’s advice, they should accept the risks involved, mainly of relapse, and a ‘Discontinuation form’
will be signed.
Retainers may be recommended and the dentist will be informed of the discontinuation decision. No refunds are
applicable for the discontinuation of treatment.
Clinical Records
Your records consist of hard copies and computer notes and include your photographs, X-rays and models. This
information is stored in accordance with the Data Protection legislation. You may have access to the information on
written request. As an orthodontic practice, we have teaching responsibilities to provide education and training for other
dentists. As a result, we may use your models, X-rays or photographs for educational or marketing purposes. This may
include professional consultations, research, education or publication in professional journals or on the internet. Once the
records are published on the internet, they are in the public domain.
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Financial responsibility
The full fees quoted for your treatment become due on the day that impressions are taken for aligner / positioner
treatment or fixed lingual treatment or the date of fitting the brace for other types of orthodontic treatment. Any
agreement for payment to be made in instalments is conditional on all payments being made on time, and with any
finance agreement in place by the time that your treatment fees are due. Failure to maintain payments will result in the
balance of your treatment fees being immediately due. Until your account is settled, only emergency treatment will be
provided. At the end of treatment, any remaining balance would be payable prior to the appliances being removed.
PostPost-treatment responsibility
We will see you 2 months and 12 months after the end of your active orthodontic treatment for retainer check-ups, these
appointments are included in your treatment fee. Any additional check-up appointments will be chargeable.
If the retainers are lost, broken or stop fitting perfectly, you must contact us immediately for repairs or replacement
retainers which will incur an additional charge.
It is YOUR responsibility to keep your teeth straight after treatment by wearing your retainers as instructed, checking them
regularly and reporting any concerns to us immediately especially if they are lost, broken, stop fitting perfectly or show
signs of wear.
Our responsibility ends by delivering the anticipated result that you are happy with, supplying retainers that fit your teeth
at the end of orthodontic treatment and giving you full instructions for the wear of these retainers. Premier Orthodontics
cannot be responsible for any adverse tooth movement, relapse or for the stability of the orthodontic result.
As explained under the section ‘Retention: Will my teeth stay in their treated position?’ your mouth changes shape
throughout life. For this reason, it is likely that if you do not wear your retainers as instructed, or if you wear them for less
time than required or if they break or get lost and you fail to inform us immediately, your teeth will move.
In case of relapse, further orthodontic treatment will be required using aligners or fixed braces to straighten the teeth
again. This is a new treatment course and additional charges will apply.
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DECLARATION (Patient Copy)
I am the patient/parent/guardian and
• I have read and understood all six pages of this consent form
• I have read and understood the treatment plan letter and agree to the proposed treatment
plan, the quoted fee and payment method
• I agree that the orthodontic treatment proposed has been explained to me and I have had the
opportunity to ask questions
• I agree that the treatment alternatives have been discussed and that I have the option to
pursue no treatment
• I agree that the charges associated with my orthodontic treatment have been explained to me
• I agree to comply with my responsibilities as stated on this form, to keep my brace clean, to
attend my appointments, to check my brace daily for breakages, and to comply with verbal
and written instructions provided throughout the treatment
• I understand that changes may need to be made to the treatment plan, but that these will be
explained in detail if required
• I understand the length of time and commitment required for the orthodontic treatment to be
effective, and that the actual treatment time may vary from the estimated treatment time.
• I understand the potential limitations, risks and drawbacks of this orthodontic treatment.
• I understand that failing to attend appointments will increase the length of time of the
treatment and multiple missed appointments, repeated breakages or continuing poor oral
hygiene will result in additional charges, treatment being paused or terminated before
completion
• I 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 understand my post-treatment responsibility as explained in the last section
I hereby consent to the treatment proposed and authorise Dr Yaz Nafa to
to provide the treatment.
Patient name.....................................................Signature............................................Date……….
If patient is under 16:
16:
Parent/Guardian name......................................Signature.................................Date………………..
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DECLARATION
DECLARATION (Practice Copy)
I am the patient/parent/guardian and
• I have read and understood all six pages of this consent form
• I have read and understood the treatment plan letter and agree to the proposed treatment
plan, the quoted fee and payment method
• I agree that the orthodontic treatment proposed has been explained to me and I have had the
opportunity to ask questions
• I agree that the treatment alternatives have been discussed and that I have the option to
pursue no treatment
• I agree that the charges associated with my orthodontic treatment have been explained to me
• I agree to comply with my responsibilities as stated on this form, to keep my brace clean, to
attend my appointments, to check my brace daily for breakages, and to comply with verbal
and written instructions provided throughout the treatment
• I understand that changes may need to be made to the treatment plan, but that these will be
explained in detail if required
• I understand the length of time and commitment required for the orthodontic treatment to be
effective, and that the actual treatment time may vary from the estimated treatment time.
• I understand the potential limitations, risks and drawbacks of this orthodontic treatment.
• I understand that failing to attend appointments will increase the length of time of the
treatment and multiple missed appointments, repeated breakages or continuing poor oral
hygiene will result in additional charges, treatment being paused or terminated before
completion
• I 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 understand my post-treatment responsibility as explained in the last section
I hereby consent to the treatment proposed and authorise Dr Yaz Nafa to provide the treatment.
Patient name.....................................................Signature............................................Date……….
If patient is under 16:
16:
Parent/Guardian name......................................Signature.................................Date………………..
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