Patient Consent Form – Orthodontic Consent

Patient Consent Form - Orthodontic Consent

Orthodontics is a treatment procedure that can provide better overall dental health and comfort, improved appearance, and enhanced self-esteem. As a rule, informed and cooperative patients can achieve positive orthodontic results. Therefore, the following information is routinely supplied to anyone considering orthodontic treatment at our practice. While recognising the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like other forms of clinical treatment, has limitations and potential risks. These are seldom enough to avoid treatment but should be considered in making decisions to undergo orthodontic treatment. Please ask any questions that you may have about this information.


Nature and purpose of treatment:


Orthodontic treatment improves the bite by helping to direct the forces placed on teeth, thus protecting them from trauma during ordinary everyday activities such as chewing and grinding the teeth. Orthodontic treatment distributes the chewing stress throughout the mouth to minimise excessive stress on the bones, roots, gum tissue and temporomandibular joints. Through orthodontic treatment potential dental problems may be eliminated, including the problem of abnormal wear. Treatment can facilitate good oral hygiene to minimise decay and future periodontal problems. Orthodontic treatment can also provide a pleasant smile and enhance one’s appearance and self-image.


Risks


All forms of medical and dental treatment, including orthodontics, have some risk and limitations. Fortunately, in orthodontic treatment complications are infrequent and, when they do occur, they are usually of minor consequence. Nevertheless, they should be considered when making the decision to undergo orthodontic treatment. The major risks involved in orthodontic treatment may include:



  1. Decalcification (permanent marking), decay, or gum disease if patients do not brush their teeth properly during the treatment. Excellent oral hygiene and plaque control is a must. Sugary foods and between-meal snacks should be avoided.

  2. Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with the healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession and delayed tooth movement during orthodontic treatment.

  3. Teeth have a tendency to rebound to their original positions after orthodontic treatment. This is called relapse. In addition, teeth tend to change their positions after treatment. This is usually only a minor change, and faithfully wearing your retainers generally reduces this tendency. Throughout life, the bite can change adversely from various causes, such as growth, eruption of wisdom teeth, or oral hygiene habits. After removing your braces, you will be provided with retainers to stabilise the result. Full co-operation in wearing these retainers is important. Discontinued retention can possibly result in some relapse. Therefore, we recommend that the retainers be worn every night of the week to preserve the orthodontic correction.

  4. 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.

  5. Inflammation of the gums and loss of supporting bone can occur if bacterial plaque is not removed daily with good oral hygiene. If the health of the bone and gums is affected during orthodontic treatment, periodontal treatment may be needed.

  6. In some cases, the root ends of the teeth are shortened during treatment. This is called root resorption. Root resorption also occurs in patients who do not undergo orthodontic treatment, and may also be caused by trauma, impaction, hormonal imbalances, and other unidentified reasons. Usually, the resorption does not have any significant consequences to the patient’s long-term dental health, but gum disease in later life could reduce the longevity of the affected teeth.

  7. A tooth that has been traumatised from a deep filling, or even a previous accident, may have suffered nerve damage. These teeth can die over an extended period of time, with or without orthodontic treatment. An undetected non-vital tooth may flare up during orthodontic treatment, requiring root canal treatment.

  8. A significant portion of the population has problems with the joints of the lower jaw, the temporomandibular joints. Some of the common symptoms of these problems are popping in the joints, pain in the joints or surrounding structures in the head and neck, and headaches. These problems may occur with or without orthodontic treatment. They can originate from several different causes, and it is possible that the problem may become evident during orthodontic treatment. Any of these symptoms should be reported to your practitioner immediately.

  9. Sometimes orthodontic appliances may irritate or damage the oral tissues. The gums, cheeks and lips may be scratched or irritated by loose or broken appliances, or by blows to the mouth. You should inform us of any unusual symptoms, or broken or loose appliances, as soon as possible.

  10. Headgear instructions must be followed carefully. If handled improperly, a headgear may cause injury to the face or eyes. Patients are warned not to wear a headgear while involved in sports activity or horseplay. Although our headgears are equipped with a safety system, we urge caution at all times.

  11. Your treatment may include the use of a temporary anchorage device(s) (i.e., metal screw attached to the bone). There are specific risks associated with these devices. It is possible that the screw(s) could become loose, break, or cause the tissue around the devise to become infected. This would require the device’s removal or replacement. Local anaesthetic may be used when these devices are inserted or removed.

  12. Sometimes oral surgery, such as tooth removal or orthogenetic surgery is necessary in conjunction with orthodontic treatment, especially to correct crowding or severe jaw imbalances. Risks involved with surgery and anaesthesia should be discussed with your general dentist or oralsurgeon before making a decision to proceed with any surgical treatment.

  13. Atypical formation of teeth or disproportionate growth of the jaws during or after treatment can cause the bite to change, requiring additional treatment and, in some cases, oral surgery. Growth disharmony and unusual tooth formations are biological processes beyond the practitioner’s control. Unusual growth changes that occur after active orthodontic treatment may alter the quality of treatment results.

  14. The total time required to complete treatment may exceed the original estimate. Excessive or deficient bone growth, poor co-operation in wearing elastics and removable appliances, poor oral hygiene, broken appliances and missed appointments can lengthen the treatment time and affect the quality of the treatment results.

  15. In the case of patients and their parents requesting that treatment be terminated, no responsibility will be accepted by the practitioner for possible later instability of the patient’s teeth or any other damage.

  16. Due to the wide variation in the size and shape of teeth, achieving the ideal result may sometimes require restorative dental treatment. The most common types of treatment are cosmetic bonding, veneers, crowns, and bridges. You are encouraged to ask questions regarding dental and medical care adjunctive to orthodontic treatment from the doctors who provide these services.

  17. Occasionally, patients could be allergic to some of the component materials of the orthodontic appliances. This may require a change in the treatment plan or discontinuation of the treatment prior to completion.

  18. General medical problems can affect the orthodontic treatment. You should keep us informed of any changes in your medical health. Orthodontic treatment does not take the place of regular check-ups. You will be expected to continue seeing your family dentist for regular six-monthly check-ups and routine care, unless you have been specifically advised that you need to be seen more frequently.

  19. Phase I ‘interceptive treatment’ is specifically intended to correct harmful conditions, or to allow growth management that will simplify subsequent treatment. If you have been advised that Phase I treatment is needed for your child, it does not usually eliminate the need for braces after the permanent teeth have erupted and is almost always followed by Phase II treatment with fixed braces. In addition to the above information, the following conditions are specific to your treatment, and have been discussed with you during the consultation: The TMJ findings were discussed with you. If any TMJ symptoms develop during or following the orthodontic treatment, further evaluation or treatment may be required.

  20. Please note that if any procedure impressions are taken, i.e., mouth guards, retainers, removable appliances, functional or fixed appliances, it is your sole responsibility to book an appointment that is no later than 10 days from the date the impression was taken to place the required appliance. Additional laboratory cost may be incurred if you fail to do so.

  21. We will not be held liable for any damage to, or loss of, dental restorations, crown and bridge work, implants, or prosthesis, either during or after orthodontic treatment, or while the clinician is debanding.


Possible Alternatives


For the vast majority of patients, orthodontic treatment is an elective procedure. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present condition and decide to live without orthodontic correction or improvement. Any specific alternatives to the orthodontic treatment have been discussed with you.


Acknowledgement of Informed Consent


I hereby acknowledge that the major treatment considerations and potential risks of orthodontic treatment have been presented to me. I have read and understand this form and understand that there may be other problems that occur less frequently and are less severe.


Fees


Upon signing this consent, you agree to the treatment as well as the cost of the treatment submitted to you in the cost report, thus entering into a contract with the practice (Locatio conductio operarum). Non-payment of the fees as per our arrangement is a breach of this contract. This would entitle the practitioner to cease treatment until an effort is made to address the outstanding balance. It is incumbent upon the patient to attend regular check-ups during this period. The length of active treatment and the length of the payment plan are two separate entitles. The fee charged is for completing treatment. Should treatment be completed before the conclusion of the payment plan, the balance will still be owed according to the payment plan. In the case of an orthodontic treatment transfer or termination (for unanticipated reasons), the practice will partake in a settlement agreement with the account holder. The settlement agreement is as follows:



  • 50% of the total treatment cost

  • Up to date payment of the current monthly instalment


The account holder will be liable for the above mentioned, within a period of 30 days from transfer or termination request.


On request, a mouth guard could be made by our laboratory; however, the cost involved will not be paid by any medical aid. If a patient requests that a part of their appliances be removed for a special occasion (e.g., matric farewell, wedding, etc.) an extra fee will be charged.


PARTICULARS OF PAYMENT AGREEMENT


Having designed a treatment plan; your practitioner will discuss financial arrangements. It is important for you to understand your obligations in this regard.


1.PARTICULARS OF THE PATIENT



  • You are responsible for keeping your practitioner informed at all times of your most recent home, work, and postal addresses, as well as home and work telephone numbers. This responsibility will only be revoked after the account for the payment of your orthodontic treatment has been fully settled.

  • All patients are solely responsible for settling their accounts


2. THE PATIENT WITH A MEDICAL AID SCHEME


2.1 You, as a member of a medical aid scheme, are responsible for establishing the following:



  1. The content and provisions of the applicable scales of benefit, as determined by your medical aid, to pay for your orthodontic treatment.

  2. The limits determined for these scales.

  3. The present standing of each benefit scale under which you may claim.

  4. The amount payable by you as a co-payment (if any) when the account is settled.


2.2 You are entitled to request from your practitioner a written confirmation of the costs of any orthodontic examination and treatment before they are performed.


2.3 Every orthodontic procedure performed and/or 
      service rendered by your practitioner rests on the
      assumption that you are fully aware of the 
   information referred to in paragraph 2.1 above. 
     Notwithstanding any inquiry by you, your  
     practitioner will not be bound by any oral estimation
     of costs that are likely to be paid by the medical aid.


2.4 You remain responsible for the full and final settlement of the account, irrespective of any membership to a medical aid.


3.PATIENT WITHOUT A MEDICAL AID SCHEME


3.1 You are entitled to request from your practitioner a written confirmation of the costs involved before any orthodontic examination or treatment is performed.


4. TRANSFER CASES



  • Sometimes the treatment of a patient has to be continued by another practitioner due to the patient’s relocation. Since payment for orthodontic treatment is made monthly as the treatment progresses, the fees incurred until the month in which the last visit to our practice was made are payable. The practitioner who agrees to continue with the patient’s treatment may wish to re-evaluate the case and may elect to change the type of braces that we fit. A separate financial arrangement will have to be discussed with the new practitioner for the continuation of treatment. The original x-rays, models, etc. will only forwarded to the new practitioner after the outstanding balance has been paid in full.

  • The aforementioned conditions are likewise binding on (i) you, the patient who is a major and (ii) you, the patient who is a minor (even if the patient’s natural parent or legal guardian is absent). Where another person undertakes to pay the account for orthodontic procedures to be performed and/or services rendered to a person, the signatory warrants that they have the authority to contract on behalf of the patient as the patient’s agent in all respects, including the authority to waive the patient’s rights as set out in this contract. The signatory indemnities the practice for any damage that the signatory may suffer from a breach of this warranty of authority.

  • In case of a dispute occurring, both parties agree to seek resolution only from the ombudsman of the SADA.

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Confirmation Payment Agreement
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Orhodontic Treatment Concent
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I hereby acknowledge that I have read the above and fully understand the orthodontic consent, treatment and financial plan
By signing this consent form, you authorise Patheodent to perform the orthodontic treatment according to the necessity of the orthodontic treatment plan and without the need for any further authorisation or consent.
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Version 1.0 (Last Updated: 2023/05/09 - 14:26)

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