[PRACTICE NAME] DENTAL MONITORING CONSENT FORM
NOTICE: This is a template provided by Orthosnap. Each practice must customize this form to align with their policies, including any financial provisions related to patient compliance.
Patient Name: ___________________________
Date of Birth: ___________________________
Parent/Guardian Name (if applicable): ___________________________
Overview
At [PRACTICE NAME], we use the Dental Monitoring device and app to track your progress with Orthosnap clear aligner treatment. This tool allows us to remotely monitor your aligner wear, ensure compliance, detect potential issues early, and adjust your aligner wear schedule as needed.
By signing this consent form, you agree to use the Dental Monitoring device and app as directed and understand the benefits and responsibilities involved.
Patient Responsibilities
Weekly Scans: You agree to use the Dental Monitoring device and app to submit clear and accurate scans of your teeth at least once per week.
Proper Usage: You will follow the instructions provided by [PRACTICE NAME] on how to use the device properly, ensuring high-quality scans for review.
Aligner Wear Compliance: Your scan data will be reviewed to determine your adherence to aligner wear. Based on compliance, your aligner wear cycle may be shortened, extended, or adjusted.
Technical Issues: You agree to notify [PRACTICE NAME] immediately if you experience any technical issues with the app or device that prevent you from submitting scans.
In-Person Visits: You acknowledge that remote monitoring does not replace necessary in-office visits, and you will still be required to attend scheduled appointments as directed.
Monitoring & Adjustments
Your scans will be reviewed by both [PRACTICE NAME] and Orthosnap’s clinical team to assess compliance and aligner fit.
Based on your scans, you may receive instructions to advance to the next aligner sooner or to extend wear time if your teeth are not tracking as expected.
If compliance is consistently poor, your treatment may be prolonged, or alternative recommendations may be made.
Compliance & Financial Policy (Practice Customization Required)
[PRACTICE NAME] reserves the right to establish financial policies related to non-compliance. (Example: If you fail to submit scans as required or do not follow instructions, additional fees may apply to continue treatment.)
Any financial consequences of non-compliance will be at the discretion of [PRACTICE NAME] and must be outlined in your individual treatment agreement.
Liability & Acknowledgment
I understand that the Dental Monitoring system is a tool for remote observation and does not replace in-office evaluations.
I acknowledge that failure to comply with scan requirements may result in extended treatment time, additional aligners, or changes to my treatment plan.
I understand that [PRACTICE NAME] and Orthosnap are not responsible for treatment delays due to my failure to submit scans or follow instructions.
Consent & Agreement
By signing below, I acknowledge that I have read and understand the responsibilities and policies outlined in this consent form. I agree to use the Dental Monitoring device and app as directed and to comply with my treatment plan.
Patient Signature: ___________________________
Date: _______________
Parent/Guardian Signature (if applicable): ___________________________
Date: _______________
Practice Representative Signature: ___________________________
Date: _______________