Informed Consent and Agreement for
Patient First Name Patient Last Name
Patient's Informed Consent and Agreement Regarding Invisalign Orthodontic Treatment
Dr. Montano has recommended the Invisalign system for your orthodontic treatment. Although orthodontic treatment can lead to healthy teeth and provide important benefits—such as an attractive smile—you should also be aware that orthodontic treatment (including orthodontic treatment with Invisalign aligners) has limitations and potential risks that should be considered before undergoing treatment.
Invisalign aligners, developed by Align Technology, Inc. ("Align") consist of a series of clear, plastic, removable appliances that move your teeth in small increments. Invisalign products combine Dr. Montano’s diagnosis and prescription with sophisticated computer graphics technology to develop a treatment plan which specifies the desired movements of your teeth during the course of your treatment. Upon approval of a treatment plan developed by Dr. Montano, a series of customized Invisalign aligners is produced specifically for your treatment.
You will undergo a routine orthodontic pre-treatment examination, including X-Rays and photographs. Dr. Montano will have a scan taken of your teeth to send, along with your prescription, to the Align laboratory. Align technicians will follow Dr. Montano’s prescription to create a ClinCheck® software model of your prescribed treatment. Upon approval of the ClinCheck treatment plan by Dr. Montano, Align will produce and mail a series of customized aligners to Dr. Montano.
The total number of aligners will vary depending on the complexity of Dr. Montano’s prescription. The aligners will be individually numbered and will be dispensed to you by Dr. Montano with specific instructions for use. Unless otherwise instructed by Dr. Montano, you should wear your aligners for approximately 20 to 22 hours per day, removing them only to eat, brush and floss. As directed by Dr. Montano, you will switch to the next aligner in the series every one to two weeks. Treatment duration varies depending on the complexity of Dr. Montano’s prescription. Unless instructed otherwise, you should follow up with Dr. Montano a minimum of every 6 to 10 weeks. Some patients may require bonded aesthetic attachments and/or elastics on their teeth during treatment to facilitate specific dental movements. Patients may require additional refinement after the initial series of aligners.
Invisalign aligners offer an esthetic alternative to conventional braces.
Aligners are nearly invisible so many people won't realize you are in treatment.
Tooth movement can be visualized through the ClinCheck® software.
Aligners allow for normal brushing and flossing tasks that are generally impaired by conventional braces.
Aligners do not have the metal wires or brackets associated with conventional braces.
The wearing of aligners may improve oral hygiene habits during treatments.
Invisalign patients may notice improved periodontal (gum) health during treatment.
Risks and Inconveniences
Like other orthodontic treatments, the use of Invisalign product(s) may involve some of the risks outlined below:
i. Failure to wear the appliances for the required number of hours per day, not using the products as directed by your doctor, missing appointments, and atypically shaped teeth can lengthen the treatment time and affect the ability to achieve the desired results;
ii. Dental tenderness may be experienced after switching to the next aligner in the series;
iii. Gums, cheeks and lips may be scratched or irritated;
iv. Teeth may shift position after treatment. Faithful wearing of retainers at the end of treatment should reduce this tendency;
v. Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush and floss their teeth properly before wearing the Invisalign products, or do not use proper oral hygiene and preventative maintenance;
vi. The aligners may temporarily affect speech and may result in a lisp; although, any speech impediment caused by the Invisalign products should disappear within one or two weeks;
vii. Aligners may cause a temporary increase in salivation or mouth dryness; certain medications can heighten this effect;
viii. Attachments may be bonded to one or more teeth during the course of treatment;
ix. Teeth may require interproximal recontouring or slenderizing in order to create space to allow tooth movement to occur;
x. General medical conditions and use of medications can affect orthodontic treatment;
xi. Health of the bone and gums which support the teeth may be impaired or aggravated;
xii. Oral surgery may be necessary to correct crowding or severe jaw imbalances that are present prior to wearing the Invisalign product. If oral surgery is required, risks associated with anesthesia and proper healing must be taken into account prior to treatment;
xiii. A tooth that has been previously traumatized, or significantly restored, may be aggravated. In rare instances, the useful life of the tooth may be reduced, the tooth may require additional dental treatment such as endodontic and/or additional restorative work, and the tooth may be lost;
xiv. Existing dental restorations (e.g. crowns) may become dislodged and require re-cementation or, in some instances, replacement;
xv. Short clinical crowns can pose appliance retention issues and inhibit tooth movement;
xvi. The length of the roots of the teeth may be shortened during orthodontic treatment and may become a threat to the useful life of teeth;
xvii. Product breakage has a higher probability in cases with multiple missing teeth;
xviii. Orthodontic appliances or parts thereof may be accidentally swallowed or aspirated;
xix. In rare instances, problems may also occur in the jaw joint, causing joint pain, headaches or ear problems;
xx. Allergic reactions may occur;
xxi. Teeth that are not at least partially covered by the aligner may undergo supraeruption;
I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Invisalign aligners. I understand the benefits, risks and inconveniences associated with treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment with Invisalign products with Dr. Montano from whom I intend to receive treatment. I understand that I should only use the Invisalign products after consultation and prescription from an Invisalign certified doctor, and I hereby consent to orthodontic treatment with Invisalign products that have been prescribed by Dr. Montano.
Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor and Align Technology, Inc. ("Align") have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Align is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give medical advice. No assurances or guarantees of any kind have been made to me by Dr. Montano or Align, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment.
I authorize Dr. Montano to release my medical records, including, but not be limited to, radiographs (X-Rays), reports, charts, medical history, photographs, findings, plaster models or impressions of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor's possession ("Medical Records") (i) to other licensed dentists or orthodontists and organizations employing licensed dentists and orthodontists and to Align, its representatives, employees, successors, assigns, and agents for the purposes of investigating and reviewing my medical history as it pertains to orthodontic treatment with product(s) from Align and (ii) for educational and research purposes.
I understand that use of my Medical Records may result in disclosure of my "individually identifiable health information" as defined by the Health Insurance Portability and Accountability Act ("HIPAA"). I hereby consent to the disclosure(s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not, nor shall anyone on my behalf, have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.
A photostatic copy of this Consent shall be considered as effective and valid as an original. I have read, understand and agree to the terms set forth in this Consent as indicated by my signature below.
Signature of Patient/Parent/Guardian Date
I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, website, marketing or publication in professional journals
Signature of Patient/Parent/Guardian Date
Treatment using “Invisalign” removable appliances
Please note that the monthly payments are not related to the number or frequency of office visits, but simply to the total time in treatment. There will be an additional charge for lost or broken appliances. Please note that with “Invisalign®” appliances, after the initial set of aligners, additional aligners are often required to refine the result. The case fee will include one set of refinement aligners for both arches simultaneously; separate refinements or more than one will involve additional fees due to Align Technologies billing policies. A fee of $1000 will be assessed if a switch to braces must be made due to non-compliance with Invisalign wear. The purpose of this fee is to offset the cost of materials and lab fees associated with switching to braces.
Responsible party’s signature Date
PATIENT SUCCESS AGREEMENT
1. Missed Appointments. Active treatment time will be extended by missed and forgotten appointments. Please call our office 24 hours in advance to change or cancel an appointment.
2. Broken or Loose Buttons. Eating the wrong foods will damage your braces. Damaged bands or brackets are not an emergency. Call our office to schedule time for a repair appointment. Remember that each loose band or bracket extends treatment time. Unlike most orthodontic offices, we do not charge for broken or lost buttons. However, in the case of egregious, repeated breakage and non-cooperation, we reserve the right to discontinue treatment.
3. Broken or Lost Appliances. The appliances are durable and should last throughout the treatment period. Occasionally, appliances need to be replaced due to loss, breakage, misuse, or careless handling on the part of the patient. Unlike most orthodontic offices, we do not charge for broken appliances. However, in the case of egregious, repeated breakage, we reserve the right to discontinue treatment. Lost appliances are subject to additional replacement charges. At the completion of treatment, one set of final retainers will be issued and any replacements will be the patient’s responsibility.
4. Cooperation. The estimated active treatment time is based on professional experience and assumes complete cooperation. Extended treatment may result from: a) repeated breakage, b) loss or careless handling of appliances, c) not carrying out the recommended treatment, d) failure to keep teeth and appliances clean, or e) missed appointments. Appliances, including elastics, must be worn as prescribed by Dr. Montano. Unlike most offices, we do not charge a monthly fee for treatment that extends beyond the estimated treatment length. Our commitment and focus is to achieve the best possible outcome. However, we reserve the right to discontinue treatment in the event of egregious noncooperation.
5. Dental Care. The orthodontic treatment fee does not include general dental care, such as cleanings, restorations, fillings, crowns, checkups, radiographs, extractions, periodontal care and oral surgery. Be sure to visit the dentist regularly for routine cleanings, dental examinations, and other necessary dental work during orthodontic treatment. Note: Fees resulting from orthodontic services rendered by another provider are the sole responsibility of the patient and/or responsible party.
6. Changes to treatment Goals. The orthodontic treatment fee covers all aspects of the treatment. Rarely, a change in treatment goals may arise during treatment. If, in consultation with Dr. Montano, a mutually agreed upon change results in a significant increase in treatment length and/or use of additional appliances (such as TADs), a corresponding charge may be added.
7. Comfort Appointments. There will be a charge for emergency appointments after office hours. Comfort appointments made during office hours will not be charged.
HOW DO I FIT ORTHODONTICS APPOINTMENTS INTO MY BUSY LIFESTYLE?
Most people seeking orthodontic treatment have important obligations during the day, usually involved with work or school. During active orthodontic treatment, each patient is seen every few months; some of these appointments will conflict with work or school.
We have devoted considerable time and effort into designing our scheduling system. Our goal with our schedule is to: see you on time for your appointment; have adequate time during each appointment to complete the necessary procedures; answer questions and update your treatment progress. We truly want to work with you to schedule around your school or work hours as much as possible. As you can imagine, a well-organized schedule requires considerable structure and flexibility.
During your treatment, there are times when the adjustments are completed quickly even though they may be very technical. We have put a lot of thought into designing treatment methods that are more convenient for you.
Longer appointments (such as Bonding, Rebonds, Banding, and Band Removal appointments) are few in number and are scheduled during school/work hours; shorter appointments can be scheduled in either the morning or afternoon. In this way, an entire afternoon is not committed to only a few patients. If you prefer to come to the office during a quieter time, please schedule an appointment during school/work hours.
Because the schedule is carefully crafted, your late arrival can pose a problem. In fairness to the other scheduled patients, we may not be able to accommodate you into the schedule and therefore may find it necessary to reschedule your appointment.
We realize that an unforeseen circumstance may arise which necessitates a change in appointments. To avoid a delay in treatment, it may be necessary to schedule an appointment during school/work hours. Missed appointments, or numerous appointment changes, will inevitably result in an extension of your treatment time.
Comfort adjustment appointments are made to accommodate patients that have pain, bleeding, or swelling related to their orthodontic treatment. This can include anything from trauma to the mouth to a poking arch wire. These patients will be seen as soon as possible; we will either give appropriate care or referral to another specialist for treatment.
To ensure that you are seen in a timely manner, please call to make an appointment and never just drop by the office.
Thank you so very much for understanding!
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I have received a copy of this office's Notice of Privacy Practices.
Notice of Privacy Practices:
You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of: our treatment, payment activities, and healthcare operations; the uses and disclosures we may make of your protected health information; and other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person: Rhonda
Address: 1010 Calloway Dr. # 200A
Bakersfield, CA 93312
Right to Revoke:
You will have the right to revoke this Consent at any time by giving us written notice of your revocation, submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.
Signature of Patient or Parent/Guardian
I have had full opportunity to read and consider the contents of this consent form and the Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
Signature of Patient or Parent/Guardian Date
PRACTICE FINANCIAL POLICIES
FINANCIALLY RESPONSIBLE PERSON:
THIS FINANCIAL POLICY is in effect for an Orthodontic treatment that will take APPROXIMATELY months. At the end of this time there will be a Retention Phase of treatment that will take approximately years.
IF SERVICES ARE TERMINATED for any reason before the completion of treatment, the account will be adjusted and a just settlement determined, based on the amount of treatment completed.
IN THE EVENT F A DECLINED AUTOMATIC DRAFT, the responsible party must contact the office within 10 days of the scheduled due date. Failure to do so may result in a late fee.
SERVICES PROVIDED BY OTHERS, Laboratories, etc., outside of this orthodontic practice are not part of the treatment fee.
IF ORTHODONTIC INSURANCE covers all or part of the fee, it may be paid directly to the practice or to the policy holder as arranged. Whatever part of the account balance not paid directly to the practice by an insurance company must be paid by the Financially Responsible Person noted below.
FINANCIALLY RESPONSIBLE PERSON SIGNATURE Date
SIGNATURE ON FILE FOR INSURANCE
I authorize the release to my insurance company or companies any information including the diagnostic records and diagnosis of any treatment required to comply with applicable law and facilitate the billing and reimbursement for the treatment provided.
Signature of Patient or Parent/Guardian Date