Informed Consent for
Patient First Name Patient Last Name
Risks and Limitations of Orthodontic Treatment
Successful orthodontic treatment is a partnership between the orthodontist and the patient. Dr. Montano and team are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful, healthy smile, you should also be aware that—as with all healing arts—orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should seriously consider the option of abstaining from orthodontic treatment by evaluating their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions, or limited orthodontic treatment, may be considered. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.
Orthodontics and Dentofacial Orthopedics are dental specialties that include the diagnosis, prevention, interception and correction of malocclusion, neuromuscular and skeletal abnormalities of the developing or mature orofacial structures.
An orthodontist is a dental specialist who has completed at least two additional years of graduate training in orthodontics at an accredited program after graduation from dental school.
Results of Treatment
Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee complete satisfaction, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist's instructions carefully.
Length of Treatment
The length of treatment depends on a number of issues, including the severity of the problem, the patient’s growth and the level of patient cooperation. The actual treatment time is usually close to the originally estimated treatment time. Treatment may be lengthened if—for example—unanticipated growth occurs, there are habits affecting the dentofacial structures, periodontal or other dental problems occur, or patient cooperation is not adequate. Therefore, changes in the original treatment plan may become necessary. If treatment time is extended beyond the original estimate, additional fees may be assessed.
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Non-prescription pain medication can be used during this adjustment period.
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions after completing your orthodontic treatment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. Changes after that time can occur due to natural causes, or habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non-removable retainers or other dental appliances made by your family dentist.
Some cases will require the removal of deciduous (“baby”) or permanent teeth. There are additional risks associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the procedure.
Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you should discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment!
Decalcification and Dental Caries
Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened beverages or foods.
The roots of some patients' teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth throughout life with severely shortened roots. If resorption is detected during orthodontic treatment, your orthodontist may recommend a pause in treatment or the removal of the appliances prior to the completion of orthodontic treatment.
A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors; it occurs most often due to the lack of adequate oral hygiene. You must have your general dentist, or a periodontist—if indicated—monitor your periodontal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.
Injury from Orthodontic Appliances
Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled, swallowed, or could cause other damage to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when orthodontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.
Orthodontic headgears can cause injury to the patient’s face or eyes. In the event of injury (especially an eye injury), however minor, immediate medical help should be sought. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. For example, sports activities and games should be avoided when wearing orthodontic headgear.
Temporomandibular (Jaw) Joint Dysfunction
Problems may occur in the jaw joints, i.e., temporo-mandibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face), arthritis, hereditary tendency to jaw joint problems, excessive tooth grinding or clenching, poorly balanced bite, and many medical conditions. Jaw joint problems may occur with or without orthodontic treatment. Any jaw joint symptoms, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary
Impacted, Ankylosed, Unerupted Teeth
Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and, generally, cannot be anticipated. Treatment of these conditions depends on the particular circumstance and the overall importance of the involved tooth; extraction, surgical exposure, surgical transplantation or prosthetic replacement may be required.
Due to the wide variation in the size and shape of the teeth/missing teeth/etc., achievement of an ideal result (for example, complete closure of a space) may not be possible. Restorative dental treatment, such as esthetic bonding, crowns or bridges, or periodontal therapy may be indicated. You are encouraged to ask your orthodontist and family dentist about adjunctive care.
As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them in order to determine when, and if, the third molars need to be removed.
Your treatment may include the use of a soft tissue laser procedure. The laser uses light to gently remove gingival tissue to expose an un-erupted tooth. Risks with this procedure are minimal but include some of the following:
Loss of attached gingival (gum tissue).
Recession of the gum line around the tooth or in-between.
Asymmetry of adjacent gum lines upon healing.
Tooth damage requiring a root canal or tooth loss.
Eye damage from unprotected exposure to laser light (patient must wear laser protective eyewear).
Additional information on laser surgery:
Any application of excess heat to the treated area must be avoided at all costs for a period of 2-3 days to minimize bleeding and promote healing.
This is an irreversible procedure.
For the vast majority of patients only a topical anesthetic is necessary; for others, a small amount of local anesthetic may be necessary on the surgical area, which also has risks. Please advise the doctor placing the device if you have had any difficulties with dental anesthetics in the past. If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discontinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.
General Health Problems
General health problems can affect your orthodontic treatment; this includes bone, blood or endocrine disorders, and many prescription and non-prescription drugs (including bisphosphonates). It is imperative that you inform your orthodontist of any changes in your general health status.
Use of Tobacco Products
Smoking or chewing tobacco has been shown to increase the risk of gum disease, and can interfere with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.
Occlusal / Interproximal Adjustment
You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby "flattening" surfaces in order to reduce the possibility of a relapse.
Temporary Anchorage Devices
Your treatment may include the use of a temporary anchorage device(s) (i.e. metal screw or plate attached to the bone.) There are specific risks associated with them:
The screw(s) could become loose. This would require removal, or possibly relocation/replacement with a larger screw.
The screw and related material may be accidentally swallowed. If the device cannot be stabilized for an adequate length of time, an alternate treatment plan may be necessary.
The tissue around the device could become inflamed/infected. The soft tissue could also potentially grow over the device, which would require its removal, surgical excision of the tissue, and/or the use of antibiotics or antimicrobial rinses.
The screws could break (i.e. upon insertion or removal). If this occurs, the broken piece(s) may be left in your mouth. If they need to be removed surgically, you will be referred to another dental specialist.
When inserting the device(s), it is possible to damage the root of a tooth, a nerve, or to perforate the maxillary sinus. Usually these problems are not significant; however, additional dental or medical treatment may be necessary.
Local anesthetic may be used when these devices are inserted or removed, which also has risks. Please advise the doctor placing the device if you have had any difficulties with dental anesthetics in the past.
If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned orthodontist and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment; I hereby consent to the treatment proposed and authorize the orthodontist indicated below to provide the treatment. I also authorize the orthodontist to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by the orthodontist, and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.
CONSENT TO UNDERGO ORTHODONTIC TREATMENT
I hereby consent to the making of diagnostic records—including x-rays—before, during and following orthodontic treatment; I consent to the above doctor and—where appropriate—staff providing orthodontic treatment prescribed by the above doctor for the individual, below. I fully understand all of the risks associated with the treatment.
AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION
I hereby authorize the above doctor to provide other health care providers with information regarding the individual’s (below) orthodontic care as deemed appropriate. I understand that once released, the above doctor and staff have no responsibility for any further release by the individual receiving this information.
CONSENT TO USE RECORDS
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, or publication in professional journals.
Signature Patient or Parent/Guardian Date
I have the legal authority to sign this on behalf of (Patient’s First and Last Name):
Relationship to patient:
PHASE I TREATMENT
The purpose of Phase I treatment is primarily orthopedic in nature. Functional orthopedic appliances are used to develop the dental arches and provide more room for permanent teeth. Different types of orthopedic appliances can redirect and manage facial development to bring the upper and lower jaws and teeth into a more ideal position. Influencing development during the growing years can greatly improve balance in jaw structure and facial esthetics. Phase I treatment is sometimes initiated to improve a specific dental problem. Specific goals will be established and are of a limited nature.
Our goals of dental arch development and proper jaw structure can greatly reduce the amount of orthodontics necessary in the future. Phase I treatment may eliminate the need for extractions and provide for a better cosmetic result than would otherwise be possible. The fee quoted is for the first phase (Phase I) of a two-phase treatment plan. The Phase II treatment fee will be quoted after completion of Phase I and a new diagnostic work-up.
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 Bands and Brackets. 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 bands or brackets. 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.
Patient First and Last Name Date
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 heath 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