Phase 1 Consent Patient Form

Phase 1 Treatment Agreement

Sometimes parents and patients are confused by two phase orthodontic treatment and the goals of early or Phase 1 treatment. This document is our attempt to help clarify two phase treatment.

The goals of Phase 1 treatment may include:

1. Correction of skeletal issues that are either better or more easily addressed in younger children (prior to eruption of all permanent teeth).

2. Correction of bite issues that if not corrected when younger, may require surgery to correct when older.

3. Creating additional space to reduce the likelihood of needing future extraction of permanent teeth.

4. Creating additional space to reduce the likelihood of tooth impaction and thus reducing the need for future surgery for the impacted tooth.

5. Reducing the risk of trauma or damage to the front teeth.

6. Cosmetic alignment of the front teeth if particularly concerning to the patient or parent.

The goals of Phase 1 treatment do NOT include:

1. Prevention of additional orthodontic treatment (99% of patients undergoing Phase 1 treatment will require a 2nd phase of treatment once all of the permanent teeth erupt).

2. Perfect alignment of the teeth (permanent or baby teeth).

3. Complete bite correction.

If an expander is part of your child’s Phase I treatment, the expander will stay in the full 9-12 months.

Once the limited goals of Phase 1 treatment are complete, we will remove orthodontic appliances and allow the remaining permanent teeth to erupt. During Phase 2 treatment (once the remaining permanent teeth erupt), we will align all of the teeth into their optimum position.

There will be additional fees for Phase 2 treatment.

Phase 1 treatment does NOT qualify for the mBrace Orthodontics Lifetime Guarantee as Phase 2 treatment is expected to be necessary.

Orthodontic insurance typically has a lifetime maximum. Any orthodontic benefit used for Phase 1 treatment will not be available for Phase 2 treatment.

Informed Consent

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.

Acknowledgement of Risk(Required)

I certify that 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.

I hereby give permission for the use of my (or my child's) orthodontic records, including photographs, for lectures, educational purposes, or research(Required)

Yes

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. PLEASE INITIAL HERE:

(2) Braces/Appliance Starts:(Required)

The down payment, minimum of $500, 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.

(3) 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

(5) 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.

(6) 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.

(7) 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.

(8) 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 at least Forty Eight (48) hours before the scheduled appointment. These payments are due immediately.

(9) 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 should treatment be extended beyond the normal customary period of time due to the patient's failure to keep scheduled appointments, maintain proper oral hygiene, wear elastics and headgear when needed, or due to repeated breakage and damage to the orthodontic appliances.

(10) 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.

(11) 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.

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)

Your Full Name(Required)

First Last

Email(Required)

Phase 1 Consent Patient Form

Phase 1 Treatment Agreement

Informed Consent

Continuation of Terms and Conditions

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