Informed consent form.
General Information and Office Policies for Orthodontic Patients
Orthodontics is like a ball game--in order to be successful everyone involved must do his or her share. The dentist. the patient, the family doctor, the parents (if the patient is a minor), relatives and friends, all have a part in this game--all are members of the team. The score at the end of the game will depend on how well they cooperation and work together. It is important. therefore, that everyone understands the rules of the game--cooperation is the key to success.
Regular appointments for adjustments are necessary. If an appointment is missed please call for another one immediately. Charges may be made for failed appointments, or when 48 hours notice has not been given. Continue to wear the appliance as a retainer to hold the changes that have been made. Do not remove the appliances without the doctor's permission. It is the responsibility of both the patient (and the parents) to remember the time and dates of scheduled appointments. and to make a new appointment for any that have been missed. After school appointments are not always available, and students must expect to miss some time from school.
We schedule our appointments so we can stay on time: however a number of problems can put us behind schedule. Traumatic or other types of emergencies do occur and we do not turn true emergencies away. Therefore, you may want to call ahead to check if we are on schedule, or drop your child off and do some errands.
Be sure to keep regular appointments for your hygiene, examination and disease prevention program. During the adjustment of the appliances. There is not sufficient time to note defects in the teeth. Therefore the hygiene and periodic examination appointments remain an important service and must not be neglected. The patient (and parents) assume the responsibility for practicing excellent daily hygiene procedures to prevent decay. decalcification and/or gingival (gum) problems.
Habits such as sucking of fingers or thumb. biting of lips. tongue or cheek. leaning chin on hand and various sleeping habits may interfere with treatment. Outside professional help may be necessary for correction of tongue thrust. The cost of this therapy is not included in our fee.
Treatment consists of slight but very exacting adjustment of delicate wires and springs. Patients can follow their regular diet. However, because of the delicacy of the wires, chewing on gum, eating any sticky candies, caramels, granola bars, and biting into ice, hard candies, whole apples, celery, carrots, rolls, and hard-crusted bread (pizza crust, corn chips, pretzels, bagels) or bones must be avoided.
If anything ever appears to be going wrong: if a band seems loose, a wire continues to poke out into your lip. elastics continue to break or pop out. you must call the office and make an appointment. Headgear must not be worn during rough play. Do not become alarmed if malocclusion appears worse than before, or if certain teeth appear quite loose. These are only normal phases of orthodontic treatment. However, if you would like to be reassured, don't hesitate to call for a consultation.
In order for us to be thorough on a child's appointment, it is necessary that most communication between the doctor and parent be made through the staff: if you want to talk with the doctor about the progress of your child's treatment, please tell the staff and you can usually come back to the treatment area.
Additional charges will be made for the following: a) lost or broken appliances: b) failed appointments: c) appliances that do not fit because they haven't been worn: d) additional appliances: e) extended treatment due to lack of cooperation or excessive breakage. It is our policy that payments be made to us directly by the patient and all insurance benefits, if any, in turn be made to the patient.
In the event that either party wishes to terminate the services because of dissatisfaction with the service, failure to keep up with the payments, patient moving our of the area, or because of lack of cooperation of the patient, then one party shall so notify the other to that effect by letter. When the service is terminated for any reason, the account shall be adjusted and just settlement shall be made in proportion to the services rendered to date. Any request to anything other than that advised by the doctor automatically releases the doctor from any further responsibility, and a REQUEST TO DISCONTINUE ORTHODONTIC CARE will be signed.
The corporation reserves the right employ any qualified doctor to perform the necessary services for the patient in the event of accident. illness, or disability.
This is to certify that I have read the above statements, fully understand their significance, and with to begin treatment.