HIPAA Consent Form

As a rule, excellent orthodontics results can be achieved with informed and cooperative patients. Thus, the following information is routinely supplied to anyone considering orthodontic treatment in our office. While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has some inherent risks and limitations. These are seldom enough to contradict treatment, but should be considered in making the decision to wear orthodontic appliances.

Perfection is our goal! However, in dealing with human beings and problems of growth and development, genetics and patient cooperation, achieving perfection is not always possible. Often, a functionally and esthetically adequate result must be accepted.

Throughout life, tooth position is constantly changing. This is true with all individuals regardless of whether they have had orthodontic treatment or not. Post‐orthodontic patients are subject to the same subtle changes that occur in non‐orthodontic patients. In the late teens or early twenties, our patients may notice slight irregularities developing in their front teeth. This is particularly true if their teeth were extremely crowded prior to treatment.

Decalcification (permanent markings), decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly during the treatment time. Excellent oral hygiene and plaque removal is a must. Enjoy sugary sweets in moderation and always brush immediately after eating sweets. If you cannot brush, at least rinse vigorously with water.

On rare occasions, the nerve of a tooth may become non‐viral. A tooth that has been traumatized from a deep filling or even a minor blow can die over a long period of time with or without orthodontic treatment. An undetected non‐viral tooth may flare up during orthodontic movement requiring endodontic (root canal) treatment to maintain it.

In some cases, the root ends of the teeth are shortened during treatment. This is called root absorption. Under healthy circumstances the shortened roots are no disadvantage. However, in the event of gum disease in later life, root absorption could reduce the longevity of affect teeth. It should be noted that not all root absorption arises from orthodontic treatment. Trauma, cuts, impactions, endocrine disorders or idiopathic reasons can also cause tooth absorption.

There is also a risk that problems may occur in the temporomandibular joints (TMJ). Although this is rare, it is a possibility. Tooth alignment or bite correction can improve tooth related causes of TMJ pain, but not in all cases. Tension appears to play a role in the frequency and severity of joint pains.

Occasionally, a person who has grown normally and in average proportion may not continue to do so. If growth becomes disproportionate, the jaw relationship can be affected and original treatment objectives may have to be compromised. Skeletal growth disharmony is a biological process beyond the orthodontist control.

The total time for treatment can be delayed beyond our estimate. Lack of facial growth, poor elastic wear, broken appliances, and missed appointments are all important factors which could lengthen treatment time and affect the quality of the result.

Regular dental check ups by your dentist will continue to be important during orthodontic treatment. It will be your responsibility to schedule your six month or annual check up/cleaning with your dentist.

True orthodontic emergencies are very rare. Many problems that arise, you may be able to temporarily fix until your next scheduled appointment. For a list of solutions, please refer to our “Home Care Information” (given at the start of treatment).

This treatment will be entered into only with your cooperation and understanding of the above‐mentioned information.

Insurance

We will submit paperwork and collect from your insurance company (ies). If for some reason, the estimated insurance is not received, I understand I will be responsible the total account balance.

Transfer

In the event you should transfer out of our office, the amount of treatment rendered will be determined and, depending on your individual case, a refund to you or final payments to us will be made on the following formula:

Lingual, Invisalign, Ph I Treatment

50%‐Earned at the time of start
30%‐Earned in the first 12 months of treatment
20%‐Earned in the second 12 months of treatment
100% Total Case Fee

Ph II Treatment

25%‐Earned at the time of start
50%‐Earned in the first 12 months of treatment
25%‐Earned in the second
12 month of treatment
100% Total Case Fee

I grant the doctor permission to display slides, models, and x‐rays of the patient for scientific or educational purposes.