Phase 1 treatment – Informed consent to early treatment

Dr Sep has recommended Phase I orthodontic treatment for you/your child. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment has limitations and potential risks that you should consider before undergoing treatment.

Device description

Phase I treatment could include appliances such as Rapid Maxillary Expander (RME), Tongue Sucking Deterrent Appliance (TSDA), Twin Blocks, Space Maintainers, braces or Invisalign aligners, which could be either fixed or removable. These appliances may contain Nickel, Stainless Steel, Titanium and other metals. Please let us know if you are allergic to any metals or alloys.

Procedure

You may undergo a routine orthodontic pre-treatment examination including radiographs (x-rays) and photographs. We may also take impressions or intraoral scans of your teeth. This insert procedure can take up to 30 minutes and can cause some discomfort. Unless instructed otherwise, you should follow up with us every 3-4 months; these appointments are generally made in advance at the practice.

Patients may require additional impressions/techniques to help with regular orthodontic treatment.

Benefits

You have been advised to receive Phase I treatment for the following reasons:

• Prevent further damage to the teeth.
• Correct the small jaw.
• Improve self-confidence.

You must remember, Phase I treatment does NOT mean that your child will not need comprehensive orthodontic treatment later (when adult dentition is established). This treatment is offered to idealise jaw sizes, reduce the chance of trauma to the front teeth, make more room for the erupting adult teeth, and to improve self-confidence that will prevent bullying at school. After the full eruption of adult teeth, we will review your child’s growth and mouth/teeth, and let you know if he or she will need comprehensive treatment in future.

Risks and inconveniences

Like other orthodontic treatments, the use of Phase I appliances may involve some of the risks outlined below:

• Failure to maintain the appliances, not using the product as directed by us, missing appointments, and erupting or atypically shaped teeth can lengthen the treatment time and affect the ability to achieve the desired results.
• Dental tenderness may be experienced from time to time.
• Gums, cheeks, and lips may be scratched or irritated.
• Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages that contain high sugar levels, do not brush and floss their teeth properly after snacks and meals, or do not use proper oral hygiene and preventative maintenance.
• The appliance may temporarily affect speech and may result in a lisp, although any speech impediment caused by the appliance should disappear within one or two weeks.
• Phase I appliances may cause a temporary increase in salivation or mouth dryness and certain medications can heighten this effect.
• Fixed appliances can come off throughout your treatment if you eat hard and sticky foods, if this happens you will be required to have it replaced as soon as an appointment is available.
• The bite may change throughout the course of treatment and may result in temporary patient discomfort.
• At the end of orthodontic treatment, the bite may require adjustment (“occlusal adjustment”)
• Atypically shaped, erupting and/or missing teeth may affect the ability to achieve the desired results.
• General medical conditions and use of medications can affect orthodontic treatment.
• Health of the bone and gums, which support the teeth may be impaired or aggravated if directions by us are not properly followed.
• Product breakage is more likely in patients with severe crowding and/or multiple missing teeth.
• Orthodontic appliances or parts thereof may be accidentally swallowed or aspirated.
• In rare instances, problems may also occur in the jaw joint, causing joint pain, headaches or ear problems.
• Allergic reactions may occur.
• In rare instances, patients with hereditary angioedema (HAE), a genetic disorder, may experience rapid local swelling of subcutaneous tissues including the larynx, HAE may be triggered by mild stimuli including dental procedures.
• Co-operation throughout treatment is your best guarantee of achieving a pleasing smile and a good bite. Failure to cooperate could force the orthodontist to change the procedures and goals of your treatment. As a last resort, treatment might have to be suspended. The consequences of early suspension may be worse than no treatment at all.

Informed consent

I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Phase I appliances. I understand the benefits, risks, alternatives and inconveniences associated with treatment as well as the option of no treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment with Phase I appliances with my doctor from whom I intend to receive treatment.

I understand that I should only use the appliances after consultation and prescription from an orthodontist and I hereby consent to orthodontic treatment with a Phase I appliance that has been prescribed by my doctor. Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor has not and cannot make any guarantees or assurances concerning the outcome of my treatment.

I authorise my doctor to release my medical records, including, but not be limited to, radiographs (x -rays), reports, charts, medical history, photographs, findings, plaster models or impressions or intra-oral scans of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor’s possession (“Medical Records”) (i) to other licensed dentists or and organisations employing licensed dentists and orthodontists for the purposes of investigating and reviewing my medical history as it pertains to orthodontic treatment (ii) for educational and research purposes.

I understand that use of my Medical Records may result in disclosure of my “individually identifiable health information” as defined by the Health Insurance portability and Accountability Act (“HIPAA”). I hereby consent to the disclosure(s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not nor shall anyone on my behalf have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.

A photostatic copy of this Consent shall be considered as effective and valid as an original. I have read, understand and agree to the terms set forth in this Consent as indicated by my signature below.

Consent to Treatment

I hereby authorise Dr Sep Tabatabaee to carry out orthodontic treatment and any other related procedures deemed necessary including radiographs, for the welfare and treatment of

Fields marked * are required.

I have had the proposed treatment plan explained to me along with the risks of orthodontic treatment explained to me, and been given a document that outlines these risks.

I confirm that the risks attached to the proposed treatment have been explained to me by my practitioner and that I fully understand those risks and have determined to proceed with treatment.

I will make every effort to attend appointments, and wear the orthodontic appliances as instructed.

I understand that any more than 3 attendance failures to appointments without at least 48 hours’ notice will incur a no-show fee of $70.

Financial Agreement

I agree to pay the fees for treatment, as outlined below:

Payment plan:

I agree to follow all of Wired Orthodontics policies and procedures and acknowledge that these will change from time to time.

I agree to the use of the records obtained by the orthodontist including photographic and X-rays images, and orthodontic models for demonstration, display or social media.

Some minor cosmetic reshaping/polishing might be performed to improve the result cosmetically.

I understand that the orthodontist does not do fillings or other general dental work. I will continue to attend for regular dental examinations, and treatment as required during the course of the orthodontic treatment.

I understand that retainers follow my orthodontic treatment. Failure to wear these as prescribed may lead to tooth movement. Fees could apply if re-treatment is needed to correct this.

I acknowledge that orthodontic appliances will not be removed if there is an outstanding account.

I acknowledge that late fees will be incurred on overdue invoices, our invoices are 30-day invoices. To avoid a late payment fee of $15 please pay new charges by the due date.

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