(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
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.
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.
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.
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 replacementAsk about 0% interest finacing options
Welcome to mBrace Frisco Orthodontics! Dr. Shireen & her team are one of the highest rated practices in the Dallas / Fort Worth area.
mBrace Frisco Orthodontics
10710 Eldorado Pkwy, STE 130
Frisco, TX 75035-6293
Email: [email protected]
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