Informed Consent

Orthodontic Patient Informed Consent

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Parent/Guardian Name (if applicable)

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Informed Consent for the Orthodontic Patient
Risks and Limitations of Orthodontic Treatment

Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff 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 no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual's specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.

Click on the hyperlink to obtain a copy:

The Smile Spot’s Risks and Limitations of Orthodontic Treatment

ACKNOWLEDGEMENT

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(s) 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(s) indicated below to provide the treatment. I also authorize the orthodontist(s) 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(s), 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, and to the above doctor(s) and, where appropriate, staff providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.

AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION

I hereby authorize the above doctor(s) to provide other health care providers with information regarding the above individual’s orthodontic care as deemed appropriate. I understand that once released, the above doctor(s) and staff has(have) no responsibility for any further release by the individual receiving this information.

TRANSFERRING PATIENT

Orthodontic treatments vary widely. Transfer will likely increase treatment fees, may involve changes in payment policies, and may change your treatment and/or appliances. When you transfer to a new orthodontist, your treatment time is often extended by the process of transfer.

CONSENT TO USE OF 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, or publication in professional journals

DELIVERY OF ORTHODONTIC SERVICES BY TELEDENTISTRY

You have elected to receive orthodontic services via Teledentistry which involves using electronic and digital communications between you as a patient or parent and your orthodontist. In providing Teledentistry services, our practice will follow the rules and regulations of the state dental board(s) in which the doctor is licensed.

THERE ARE RISKS AND LIMITATIONS WITH TELEDENTISTRY FOR ANY DENTAL TREATMENT INCLUDING ORTHODONTICS:

• Unfortunately, some of the conditions that lead to adverse outcomes in orthodontics are difficult, if not impossible, to diagnose and treat without an in-person examination and if not diagnosed can lead to long term problems. These conditions include, but are not limited to, periodontal disease (disease of the gums and bone), root resorption (shortening of the roots of the teeth) and oral pathology (lesions that may be harmful), all of which require radiographs and/or other imaging techniques to identify. These potential complications and others are discussed in more detail in our Comprehensive Informed Consent document which we will ask you to review.

• The photography or digital imaging you provide to us can only give a superficial view and may be inadequate to identify all areas of concern. Although we strive to provide excellent service using Teledentistry, treatment or recommendations based solely on Teledentistry may not allow adequate monitoring of oral conditions, treatment progress or unexpected responses to treatment.

• When using electronic and digital communication in the provision of care, there is potential for the breach of confidentiality and/or inadvertent access of protected health information by someone other than your orthodontist, as well as a risk that a loss of electronic communication could mean the loss of Teledentistry services.

• In-person office visits are preferred for the best orthodontic outcomes. Teledentistry involves risks that an office visit might avoid, and Teledentistry is best used when an office visit is impractical or in between regular office visits. Your orthodontist will use his/her best judgment in determining when Teledentistry is appropriate.

Do you understand the risks and limitations of teledentistry (outlined above) and hereby consent to forwarding patient-identifiable information to our practice using electronic communications?

Yes No

Consent to treatment using Teledentistry?

Yes No

Form Completion

I have the legal authority to sign this on behalf of the patient.

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Orthodontic Patient Informed Consent

Form Completion

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