Invisalign Consent Patient Form

Informed Consent for the Invisalign Patient

PATIENT COOPERATION(Required)

The total time required to complete treatment may exceed our estimate. Excessive bone growth, poor oral hygiene or poor cooperation in wearing the appliance 21 to 22 hours per day, broken appliances and missed appointments can lengthen the treatment time, increase treatment costs, and affect the quality of the end results.

COMPLETION OF TREATMENT WITH or WITHOUT BRACES(Required)

Our office is proud of our results with patients that have completed Invisalign treatment. We have offered a small percentage of our patients the option of standard braces to achieve more ideal results than we were able to get with Invisalign alone. If this option is offered, it is without additional fee and the decision is made by the patient and the doctor. However due to non compliance with tray wear or unreasonable patient expectations if a switch to braces is made, that will be at an additional cost to the patient ( at minimum additional $750) as determined by the doctors at mBrace Orthodontics.

REFINEMENTS(Required)

The total cost of treatment includes the first series of trays and up to a maximum of 2 Refinements or additional series of trays. However due to non compliance with tray wear or multiple missed appointments or unreasonable patient expectations there will be an additional cost to the patient ( at minimum additional $750) and/or termination of treatment as determined by the doctors at mBrace Orthodontics.

DENTAL DISEASE, DECALCIFICATION(Required)

Tooth decay, gum disease and permanent markings on teeth are fully preventable, but can occur if Invisalign patients eat food containing excessive sugar and/or do not clean their teeth frequently and properly.

NON-VITAL TOOTH(Required)

An injured tooth can die over a period of time with or without Invisalign treatment and it may not be obvious that a tooth was previously injured. This tooth may flare up during Invisalign movement and require root canal treatment. This occurrence is seldom due to Invisalign and is more frequently related to a previous accident. Your general dentist would need to perform a root canal treatment if the tooth should flare up before, during, or after Invisalign treatment.

ROOT RESORPTION – SHORTENING OF THE ROOTS(Required)

This can occur with or without Invisalign treatment. Under healthy conditions, the shortened roots usually are not a problem. In very rare cases, shortened roots can be a cause of loose teeth.

PERIODONTAL PROBLEMS(Required)

Swollen, inflamed and bleeding gums can usually be prevented by proper and regular flossing and brushing. Periodontal disease can become serious and cause the loss of teeth. Should the condition become uncontrollable, Invisalign treatment may have to be discontinued short of completion. This would be rare, usually in adults with a pre-existing periodontal problem.

RELAPSE(Required)

Teeth have a tendency to partially rebound toward their original positions after treatment. Rotations and crowding of lower anterior teeth are most common examples. Teeth also tend to drift forward in the mouth over the years. We advise wearing retainers every night for the first year, and most every night from then on to avoid these biological changes. Usually a high percentage of the correction and good cosmetics can be maintained when retainers are worn in this manner.

SLENDERIZING AND RESHAPING TEETH(Required)

In attempting to straighten the teeth, but keep the removal of any teeth to a minimum, we often sand away small amounts of tooth enamel between teeth, We also may reshape the sides or edges to improve shape.

ALLERGIC REACTIONS(Required)

Allergies to medicines and Invisalign materials may occur during treatment. If you are aware of these allergies they can be avoided, but of they are unknown to you, it is impossible to predict any reaction.People who are already allergic to certain foods are more prone to allergies to materials. Some allergies that we are aware of include latex (gloves and rubber bands) and metals (such as Nickel).

TEMPORO-MANDIBULAR JOINT DISFUNCTION (TMJ)(Required)

Patients with malocclusions may have a high potential for TMJ (or temporo-mandibular) problems,which may become evident before, during or after Invisalign treatment. These may include joint pain,ear pain, and/or headaches. Invisalign treatment may help Improve the dental causes of the TMJ Syndrome but not the non-dental causes. TMJ problems can be both painful and expensive to treat. We may need to refer you to a doctor who specializes in TMJ problems, and this would be a separate fee at that doctor’s office.

IF THE PATIENT IS STILL GROWING(Required)

Occasionally, unexpected or abnormal changes in the growth of the jaws or shape and size of the teeth may limit our ability to achieve the desired result. If growth becomes disproportionate, the bite mayCHANGE, requiring additional treatment or, in some cases, oral surgery. Growth disharmony is a biological process beyond the orthodontist’s control.

UNUSUAL OCCURRENCES(Required)

Sometimes Invisalign appliances may be accidentally swallowed or aspirated, or may irritate or damage the oral tissue. Teeth may be chipped or restorations (fillings or crowns) dislodged.

TREATMENT OPTIONS -- COSMETIC RESULTS ONLY, TOOTH EXTRACTIONS, or ORAL SURGERY(Required)

Sometimes to obtain more than just cosmetic improvements, simple or even complex oral surgery could be necessary in conjunction with Invisalign treatment, especially to correct severe jaw imbalances. We suggest that if you are considering this option, that you discuss risks with your oral surgeon before making your decision to proceed with the surgery. If you decline the option of “ideal treatment” we will explain as best we can the cosmetic improvements to the smile that are possible without surgery.

CLEAR BUTTONS and TOOTH COLORED ATTACHMENTS(Required)

If attachments or buttons are needed on the front teeth, they do show more than if we do not need them. These auxiliaries are commonly needed and we request your permission to use these when needed. There is a very slight risk that some of the tooth’s enamel may be removed inadvertently.

DENTAL CHECK-UPS(Required)

Each Invisalign patient MUST be under the care of a general dentist, and your general dentist may refer adult patients to a periodontist (gum specialist). It is essential that Invisalign patients have regular dental check-ups and cleanings as directed by your general dentist (usually in intervals of 3 to 6 months between cleanings).

SPACES BETWEEN TEETH(Required)

Completion of Invisalign treatment, especially in adults, can result in slight spaces between some teeth. This is especially true if teeth were extracted, or if the widths of individual teeth are inconsistent. Also, in some adults with very crowded teeth, the gum tissues do not fill in, so there appears to be a space between teeth due to missing gum tissue.

ACKNOWLEGEMENT OF RISK(Required)

I have read, understood, and have had all my questions regarding the risks and limitations of treatment answered. I further understand that one of the alternatives is no treatment. I also understand that should any of the above conditions threaten the health of this patient, treatment may be terminated.

Continuation of Terms and Conditions

(1) Payment Plan(Required)

The monthly installments you owe DO NOT reflect the amount due for specific work accomplished or services provided at a particular date or as of a particular date. Scheduled monthly installments and payments are due at each month, regardless of whether or not the patient has an appointment or sees an orthodontist in that month.

(2) Invisalign Starts(Required)

The down payment, minimum of $550, will be non-refundable if treatment is cancelled after scan is submitted to Invisalign. Once the aligners have been approved and manufactured there is a $1800 non-refundable fee that is the patients responsibility.

(3) Braces/Appliance Starts(Required)

The down payment, minimum of $550, will be non-refundable if treatment is cancelled after braces (upper or lower) or appliance is cemented. The Transfer Fee will be applied if applicable.

(4) Dental Services Not Included(Required)

The fee for orthodontic treatment covers all treatment done in this office including insurance co-payment, with the exception of replacing lost or broken appliances. Your fee does not cover any procedures done by your family dentist or another specialist. If your hygiene is unsatisfactory, it may be necessary to remove braces. A fee will be charged to replace any braces that have been removed due to poor hygiene.

(5) Transfer Fee. (Required)

In the event that treatment is continued in another office such as when a patient moves to another community, the cost of treatment will be based on an initial fee and monthly payments up to the last visit in our office. A reasonable fee will be charged to cover costs incurred in searching, handling, copying and mailing medical records.
- 30% of your fee is for the Treatment Plan & Braces
- 60% is based on # of months completed out of estimated treatment time
- 10% is for the debond + 1 year of Retention

(6) Payment Collections(Required)

If any monthly installment payment is ninety (90) or more days delinquent, we may retain a collection agency to pursue collection of any and all amounts due under this Agreement, regardless of whether treatment is complete or the Patient i receiving ongoing active treatment. We will charge a fee of $35.00 for each check or other negotiable instrument you issue as payment on the Agreement and that is returned or dishonored for any reason.

(7) Late Fee(Required)

You will be charged a late fee amount of 1% of the past due balance not to exceed more than $25, for each payment more than thirty (30) days late.

(8) Brace Removal(Required)

If the treatment is completed for any reason before you have made each of the monthly installment payments due under the original payment schedule, the unpaid balance of the Amount Financed is immediately due and payable in full.

(9) Additional Charges(Required)

For lost or broken appliances, you will be responsible for a reasonable replacement charge, including the cost of the materials and their placement on the patient. This amount is not included in the Amount Financed, since it would penalize patients who avoid breakage or loss. We will replace six (6) broken or lost brackets at no charge. Thereafter, you agree to pay $40.00 per bracket at the time we replace each lost or broken bracket. You also agree to pay $25.00 for each scheduled appointment the Patient fails to keep with us, unless you or the Patient notified us of the cancellation atleast Forty Eight (48) hours before the scheduled appointment. These payments are due immediately. There will be an additional $150 charge per arch for patients requesting a fixed (bonded) retainer in addition to the clear retainers already provided.

(10) Patient Cooperation(Required)

It has been explained to you that the average orthodontic treatment can vary. The estimated cost of treatment is provided assuming full patient cooperation. The orthodontist reserves the right to increase the planned cost of treatment (with a minimum treatment overrun fee of $750) should treatment be extended beyond the normal customary period of time due to the patient's failure to wear their invisalign trays as recommended, keep scheduled appointments, maintain proper oral hygiene, wear elastics and headgear when needed, or due to repeated breakage and damage to the orthodontic appliances.

(11) Appointment Scheduling. It will be necessary to have all lengthy appointments during morning hours(Required)

If an excuse is necessary, we will be happy to provide one. Since after school appointments are quite popular, we try to see patients for their shorter check-up appointments later in the day. For fairness, we ask that you alternate during school appointments and after school appointments. We ask for your cooperation and understanding in this matter.

(12) Delinquent Account(Required)

In the event of a delinquent account, the following is applicable: a. Active treatment is suspended. b. Patients requiring emergency care will be treated for 30 days. c. The patients/parents may seek services at another office after a release letter is signed by Dr. Irani. d. The appliances may be removed after a release letter is signed requesting premature appliance removal. e. Active treatment will continue when the account is current.

Your Full Name(Required)

First Last

Email(Required)

Orthodontic treatment is usually an elective procedure. It, like any other treatment of the body, has some risks and limitations. These seldom prevent treatment, but should be considered in making the decision to undergo treatment.

COOPERATION IS A PREDICTABLE FACTOR THAT CAN AFFECT THE OUTCOME OF TREATMENT

In the vast majority of orthodontic cases, significant improvements can be achieved with patient cooperation. Excessive treatment time and/or compromised results can occur from non-cooperation. For example:

1. Caring for appliances – Poor oral hygiene increases the risk of discoloration (white spots) and/or decay of enamel, as well as for periodontal disease. Check-ups every 3 to 6 months with your general dentist or pediatric dentist are still necessary during the time you are undergoing orthodontic care.

2. Wearing appliances, headgear and elastics – Forces placed on teeth help move them into their proper relationships. The amount of time these devices are worn affects the results. Please wear them as instructed.

3. Keeping appointments – Missed appointments may create scheduling problems and lengthen treatment time.

UNPREDICTABLE FACTORS THAT CAN AFFECT THE OUTCOME OF ORTHODONTIC TREATMENT:

1. Oral Habits – Mouth breathing; thumb, finger, or lip sucking; tongue thrusting or posture; and other habits can prevent the teeth from moving to their correct position or cause relapse after braces are removed.

2. Facial Growth Patterns – Unusual skeletal patterns or unpredictable facial growth may compromise the occlusion (fit) of upper and lower teeth. Surgical assistance may be recommended in these situations.

3. Post Treatment Tooth Movement – Teeth may have a tendency to shift or settle after treatment, as well as after retention. Some changes are desirable, while others are not. Long-term use of retainers is advised.

4. Temporomandibular Joint (TMJ) Problems – TMJ problems may develop at any time: before, during, or after orthodontic treatment. Tooth position, occlusion, or pre-existing TMJ problems can be a factor in this condition. Often, an occlusal guard, or night guard, may be helpful.

5. Impacted Teeth – When moving impacted teeth (teeth unable to erupt normally), especially canines, various problems may be encountered, which may lead to periodontal problems, relapse, or loss of teeth.

6. Root Resorption – Shortening of root ends can occur when teeth are moved during orthodontic treatment. Under healthy conditions, the shortened roots usually pose no problem. Trauma, impaction, endocrine disorders, or idiopathic (unknown) reasons can also cause this problem. In rare cases, severe resorption may increase the possibility of premature tooth loss.

7. Non-vital or Dead Tooth – Injuries to a tooth, such as from a fall, can damage the pulp inside the tooth, causing the pulp to die. As a result, these teeth may discolor or flare up at any time, with or without orthodontic treatment. If this happens during orthodontics, tooth movement may be temporarily stopped so that the tooth may undergo endodontic root (canal) treatment.

8. Periodontal Problems (gum disease) – This condition can be present before orthodontic treatment or develop during treatment. It could deteriorate during treatment causing loss of bone around the teeth. Excellent oral hygiene and frequent cleanings by your dentist can help control this situation.

9. Unusual Occurrences -- Swallowing appliances, chipping teeth, and dislodging of restorations can occur.

10. Medications -- Some medications (e.g. bisphosphonates) may affect or prevent tooth movement.

I HAVE READ THIS FORM AND UNDERSTAND THE RISKS AND LIMITATIONS INVOLVED WITH ORTHODONTIC TREATMENT. I HEREBY CONSENT TO ORTHODONTIC TREATMENT, INCLUDING ANY RELATED PROCEDURES, SUCH AS X-RAYS, IMPRESSIONS, DIGITAL SCANS, ETC.

Initial Here(Required)

I HEREBY GIVE PERMISSION FOR THE USE OF MY ORTHODONTIC RECORDS, INCLUDING PHOTOGRAPHS, FOR LECTURES, EDUCATIONAL PURPOSES, OR RESEARCH.

Records Permission

Yes

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.

Initial Here(Required)

Consent for the Treatment of a Minor

Is this treatment for a minor under your care?(Required)

Yes

I, being the parent or guardian of said minor, hereby authorize the examination and treatment of: Name of Minor(Required)

who is a minor child. I have the authority to grant such consent. This authorization permits you to take x-rays, and to perform those procedures which are necessary for the patient’s dental health. This authorization shall remain in effect until I cancel it. I understand that I am financially responsible for payment in full at time of treatment unless other arrangements have been made in advance. By signing this statement, I agree to be responsible for payment in whole or in part.

Relationship to minor patient:(Required)

RETAINER PROGRAM: $880 ($1,280 if purchased after start of treatment)

Replacement of any lost, broken or damaged clear retainers for 6 years.
Maximum production of four Essix (Clear) Retainers annually
$20 co-payment due at time of retainer replacement
Ask about 0% interest finacing options

Do You Want to Opt in to the Retainer Program(Required)

Yes

No Thanks

I understand that replacement retainers start at $250 per arch each time(Required)