Here is an example Patient Consent form. Feel free to modify this to reflect the values of your practice (the consent form is between the Doctor and the Patient). You can use this link to download an example of a patient consent form or copy the text below to create your own.
About treatment with OrthoSnap
OrthoSnap clear aligner therapy is an orthodontic treatment in which the patient wears a series of clear, removable aligners that gradually move the teeth to improve bite function and/or esthetic appearance. As with other treatments of the body, much of its success depends on the understanding and cooperation of the patient. To that end, the purpose of this document is to inform you of some of the key benefits and potential risks associated with OrthoSnap clear aligner therapy. You should be aware that all orthodontic treatment—whether clear aligner therapy or traditional braces—has some limitations, inconveniences and potential hazards. The benefits of OrthoSnap clear aligner therapy generally outweigh the potential risks, but all factors should be considered before making the decision to wear aligners.
Please read this information carefully, and ask the doctor or staff to explain anything you do not fully understand. Ensure you know what is expected of you as the patient (or as the parent/guardian of a young patient) during treatment.
Key benefits of OrthoSnap treatment
OrthoSnap clear aligner therapy not only offers the end benefits of traditional “wired” orthodontic treatment, such as straight teeth and improved bite function, it also offers unique benefits during treatment that are only available when going wireless.
Clear No wires. No brackets. No need to hide your smile. The aligners are so clear, many people won’t even notice you wearing them. Smile all you want.
Comfortable OrthoSnap aligners are comfortable to wear. There are no cuts or abrasions from wires or brackets like with traditional braces.
Convenient With OrthoSnap clear aligner therapy, there is often less time spent at the doctor’s office than with traditional braces.
Removable Because the aligners are removable they allow you to eat, drink, brush, and floss with complete freedom.
Potential risks of clear aligner therapy
As with other orthodontic treatments, clear aligner therapy may carry some of the potential risks described below:
Treatment time may exceed our estimates. Poor compliance to your doctor’s instructions, not wearing aligners the required number of hours per day, missed appointments, excessive bone growth, poor oral hygiene and broken appliances can lengthen treatment time, increase the cost, and affect the quality of the end results.
Unusually shaped teeth can also extend treatment time. For instance, short clinical crowns can cause problems with aligner retention and slow or prevent teeth movement.
Tooth decay, periodontal disease, decalcification (permanent markings on the teeth), or inflammation of the gums may occur if proper oral hygiene and preventative maintenance are not maintained, whether wearing aligners or otherwise.
Sores and irritation of the soft tissue of the mouth (gums, cheeks, tongue and lips) are possible but rarely occur due to wearing aligners.
Initially, the aligners may temporarily affect your speech. Patients generally adapt quickly to wearing aligners and it is rare that speech is impaired for an extended period of time.
While wearing aligners, you may experience a temporary increase in salivation or dryness of the mouth. Certain medications can increase this.
Specially fabricated activators may be necessary to successfully complete your orthodontic treatment. When you are not wearing your aligners, these activators can feel awkward in the mouth.
In cases of crowding, interproximal reduction may be required to create enough space to allow teeth movement.
Any medication you may be taking and your overall medical condition can affect your orthodontic treatment.
Though uncommon, allergic reactions to the material used during treatment may occur.
Tooth sensitivity and tenderness of the mouth may occur during treatment—especially when advancing from one aligner to the next.
Bone and gums, both of which support the teeth, can be affected by wearing aligners. In some cases, their health may be impaired or aggravated.
Oral surgery may be required to correct excessive crowding or severe, pre-existing jaw imbalances. All risks of oral surgery, such as those associated with anesthesia and proper healing, must be considered before treatment.
Wearing aligners may aggravate teeth—previously traumatized or not. Though a rare occurrence, such teeth may require additional dental treatment such as endodontic treatment or other restorative treatment, the useful life of the teeth may be shortened or the teeth may be lost completely.
Existing dental restorations, such as crowns and bridges, may be affected by wearing aligners. They may become dislodged and require re-cementation or in some instances, replacement. Before any dental restorations are replaced or added, consult your doctor as they can affect the way your aligners fit.
Teeth may supra-erupt if not at least partially covered by the aligner.
Root resorption (shortening) can occur during any type of orthodontic treatment, including clear aligner therapy. Shortened roots are of no disadvantage under healthy conditions. In rare cases, root resorption can result in loss of teeth. There is no way to foresee if this will occur during your treatment and nothing can be done to prevent it.
In cases of multiple missing teeth, it is more likely that the aligner may break. Contact your doctor as soon as possible to replace it.
Because orthodontic appliances are worn in the mouth, accidentally swallowing or aspirating the aligner—in whole or in part—may occur.
Though rare, problems may occur in the jaw joint, causing joint pain, discomfort, headaches or ear problems. Inform your doctor of any such problems immediately.
Results may relapse if proper retainer wear is not followed as directed by your doctor.
Difficulty removing aligners may occur if you have multiple engagers in place during treatment, and/or excessive crowding, and/or some particular bite patterns. The doctor will give instructions to assist you if this is the case.
In some cases, due to the anatomy of the teeth, additional cosmetic dental procedures, for example, crowns, veneers, etc., may be necessary to complete treatment. There may be an additional cost to you if you require such procedures.
Informed consent & agreement
I have read and understood the content of this document describing OrthoSnap clear aligner therapy, an orthodontic treatment in which the patient wears a series of clear, removable, aligners that gradually move the teeth to improve bite function and/or esthetic appearance. I have been sufficient informed and my questions adequately answered. I fully understand the benefits and risks associated with OrthoSnap clear aligner therapy, and I hereby consent to receive
OrthoSnap clear aligner therapy as planned and prescribed by my doctor.
As clear aligner therapy is not an exact science, I acknowledge that my doctor and OrthoSnap Inc. (“OrthoSnap”), its employees, representatives, successors, assigns, and agents have not, cannot and will not make any promises or guarantees as to the success of my treatment or give any assurances of any kind concerning any particular result of my treatment. I understand OrthoSnap is not a provider of dental, medical or health care services and cannot practice dentistry, medicine or give medical advice.
I understand before beginning or, in some cases, during treatment it will be necessary to take impressions, radiographs (x-rays) and photographs for diagnosis, professional review by my doctor or other consulting dentists and orthodontists, research and education, and case submission to OrthoSnap I authorize my doctor to release such medical records, including, but not
limited to, the aforementioned. I recognize that use of my medical records may cause for disclosure of certain information deemed “individually identifiable health information” by the Health Insurance Portability and Accountability Act (“HIPPA”). I hereby consent to such disclosure(s) as described above without compensation, with the understanding I will not, nor shall anyone on my behalf, have claim of compensation or right of approval, now or in the future. I also acknowledge I will not, nor shall anyone on my behalf, seek or obtain damages or remedies—legal, equitable, monetary or otherwise—arising from any use of my medical records that complies with the terms of this Consent.
I acknowledge I have read, understand and agree to the terms of this Consent.
Signature of Patient or Parent/Guardian (if patient is minor)