Self Assessment
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orthodontic treatment
File Number:
Informed Consent for Orthodontic Treatment
Recommended Treatment
I hereby give consent to Dr.
to perform Orthodontic Treatment procedure(s) on me or my dependent as follows:
and any such additional procedure(s) as may be considered necessary for my well- being based on findings made during the course of the Recommended Treatment. The nature and purpose of the Recommended Treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.
Treatment Alternatives
Alternative methods of treatment have been explained to me, such as:
but I wish to proceed with the Recommended Treatment described above.
Patient’s Responsibility
It is the patient’s responsibility to:
1. Follow brushing and oral hygiene instructions that are given, so no harm will come to tissues and teeth;
2. Adhere to food restrictions to keep from damaging teeth and orthodontic appliances;
3. Timely come to all appointments;
4. Wear elastics, retainers, and headgear, if they are necessary, so treatment time will be as short as possible and to achieve best results; and
5. Visit the general dentist at least every six months for cleaning and examination.
6. Additional orthodontic charges may be incurred for replacement of appliances due to patient neglect, or excessive extension of treatment caused by failure of patient cooperation. Patient cooperation is critical.
Risks and Complications
I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment. These potential risks and complications, include, but are not limited to, the following:
1. Decalcification (permanent markings), decay or gum disease.
2. Root resorption resulting in teeth being shortened during treatment.
3. Pre-existing, non-vital, devitalization, traumatized teeth may cause damage to the nerve requiring a root canal on the affected tooth. Severe cases may result in tooth loss.
4. TMJ (temporo-mandibular joint) pain which may include jaw joint noises, discomfort and facial pain related to the jaw during or after treatment.
5. Discomfort due to adjustment and application of appliances.
6. Oral surgery/extractions, which may be needed to correct jaw imbalances or to remove third molars that may develop and change alignment.
7. Teeth may become impacted (trapped below gums or bone), fail to erupt, or ankylosed (fused to bone), which may require extraction, surgical transplantation/exposure, or prosthetic replacements.
Patient Name
Patient Signature
Date/Time
Parent or Guardian (if patient is minor)
Witness
Patient Signature
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