Informed Consent for the Invisalign Patient
Continuation of Terms and Conditions
Lifetime Guarantee Agreement
1. mBrace Orthodontics offers a lifetime satisfaction guarantee to all patients that have completed comprehensive orthodontic treatment with full braces or Invisalign at mBrace Orthodontics. This lifetime satisfaction guarantee DOES NOT apply to Phase 1 (early) orthodontic treatment, limited orthodontic treatment or transfer patients (those that did not begin or complete orthodontic treatment in our office).
2. If at any point after completing orthodontic treatment patient is unsatisfied with the results, mBrace Orthodontics will retreat the patient with traditional metal braces. Simply pay a monthly fee of $189/month until you are once again satisfied with your smile. If patient elects retreatment with a treatment modality other than traditional metal braces (such as clear braces or Invisalign), then the patient or responsible party will be responsible for paying any additional fees and/or laboratory fees associated with that option – even if the patient’s original treatment was with an alternative modality. There will be a $250 charge per arch (upper/lower) for new retainers following completion of retreatment.
3. This lifetime satisfaction guarantee is between the patient and mBrace Orthodontics and not any individual doctor, partner or employee of mBrace Orthodontics.
4. In order for this guarantee to remain valid, patient’s original comprehensive orthodontic treatment must have been completely paid as per the initial financial agreement with no payments ever being more than 30 days past due.
5. At the time of request for retreatment, patient must be periodontally healthy and cavity free and at the doctor’s request must receive clearance as such from a licensed Texas dentist.
6. mBrace Orthodontics reserves the right to refuse retreatment, if the doctor believes that additional orthodontic treatment may harm the patient’s dental or overall health.
7. Lifetime guarantee does not apply if patient is not satisfied with the shape, size or color of his/her teeth, because orthodontics is unable to solve these concerns. If the patient would like changes in the size or morphology of any teeth, we would be happy to refer you to a cosmetic dentist.
8. Guarantee is void if patient/parent/legal guardian signs a form requesting early removal of orthodontic appliances.
9. Guarantee is void if patient has additional orthodontic treatment (including retainers) performed by someone other than doctors employed by mBrace Orthodontics.
Guarantee is void if patient does not comply with treatment recommendations including elastic wear, oral hygiene, headgear wear, dental cleanings, periodontal maintenance, restorative dentistry or oral surgery.
11. Guarantee is void if patient had more than ten (10) broken brackets during the original treatment.
12. Guarantee does not cover dental work completed by doctors not employed by mBrace Orthodontics.
13. There are certain orthodontic conditions such as anterior open bites that have a high rate of relapse even with excellent retainer wear. mBrace Orthodontics will attempt to retreat these conditions but warns the patient there is still a high likelihood of relapse once again.
14. Lifetime satisfaction guarantee is limited to two retreatments.
Consent for the Treatment of a Minor
RETAINER PROGRAM: $880 ($1,280 if purchased after start of treatment)