PATIENT INFORMATION FORM and ORTHODONTIC SERVICE AGREEMENT
I appreciate your confidence in selecting our office for your orthodontic treatment. I want you to be fully informed and feel free to ask me questions at any time. Please understand that an important part of your treatment includes making models, x-rays and photographs for your records.
As a rule, excellent orthodontic results can be achieved with informed and cooperative patients, so I routinely supply the following information to all my patients considering orthodontic treatment. While recognizing the benefits of a pleasing smile and healthy functional teeth, you should also be aware that orthodontic therapy, like other treatment of the body, has some hazards, inconveniences and limitations. Those drawbacks seldom outweigh the long-range benefits, should be considered when making a decision to wear orthodontic appliances (braces). Orthodontic treatment is only limited to dental/teeth alignment & leveling. And it is not designed to treat orthognathic facial deformation, tooth contouring on abnormal size and shape of a tooth and does not do any facial contouring.
DISCOMFORT: When appliances are first fitted, and sometimes at routine patients visits when the appliances maybe modified or tightened, the patient can expect some discomfort and perhaps even some soreness. The discomfort generally appears after a few days. If it persists longer, please call me, as I may need to examine the patient and perhaps modify the appliance adjustments.
DENTAL HYGIENE: Decalcification (permanent marking on the teeth), tooth decay or gum disease can occur during orthodontic therapy if patients do not brush and floss properly and thoroughly, as instructed. Chewing gum, candy excessive sugars and between meal snacks are to be eliminated. Regular dental check-ups are necessary to check for tooth decay and sometimes to clean the teeth. Occasionally, gum disease problems that were present before orthodontic treatment may be worsened by the wearing of braces and may require further dental treatment of a non-orthodontic nature. The dentist will be requiring the patient to do all needed oral rehab treatment prior and during the orthodontic treatment such as (cleaning, periodontal therapy, restoration, odontectomy and tooth extraction.
IRREGULARITIES: Tooth positions constantly change throughout life, whether an individual has worn braces or not. After orthodontic treatment is completed, patients are subject to the same subtle changes that occur in non-orthodontic patients. In the late teens and early twenties orthodontic patients may notice slight irregularities developing in their front teeth, particularly if their teeth were extremely crowded prior to treatment. Long-term wearing of a retainer may be the only way to prevent this if it became undesirable.
NON-ORTHODONTIC CARE: Cold sores, canker sores and irritation or injury to the mouth are possible while wearing braces. Allergic reactions to some of the dental materials or medications are rare, but do occur occasionally. There may be a need for extraction of teeth or replacement of fillings, crowns, bridges, gum treatment or other dental procedures during or after orthodontic therapy. If this treatment becomes necessary it is not part of the orthodontic treatment.
NERVE INJURY: On rare occasions, the nerve of a tooth may become inflamed or diseased. Usually, this is due to a deep filling irritation, or by a blow the tooth has sustained. Any such nerve or endodontic treatment are considered non-orthodontic dental procedures.
RESORPTION: In some instances, the root ends of some teeth may be seen in the x-rays to shorten slightly during treatment. This is called root resorption. Under healthy circumstances, the shortened roots are no disadvantage. There is no way no foresee whether this will occur and nothing can be done to prevent this from happening.
EARLY COMPLETION OF TREATMENT/OPERATION: If the treatment and/or operation are completed before the payment period as stipulated above, the remaining balance become immediately due and demandable, otherwise the SECOND PARTY shall issue post dated checks for remaining balance for every month of unpaid balance.
NON-COMPLIANCE: Patients who are not complaint, such as a consecutive three months missed adjustments, the dentist has the right to remove the appliance and discontinue the said treatment as it will result into a more serious problem. Patient will shoulder the debonding and cleaning. The patient should also pay the previous months of adjustment.
Total Cost of Orthodontic service is 50 000 to 150,000 includes oral prophylaxis (on a case to case basis). Appliance after treatment like dental implants, dental esthetics, bridgework, crown, removable dentures, and other procedures are excluded. Retainers (vacuumed retainers) are free. If the patient is fully paid.
Therefore, patient agrees to pay a down payment and the balance will be payable in installment basis, minimum of 1,000-2,000 per month until full payment is settled, whether treatment is completed ahead of estimated period.
Lost and damage of the appliances installed during treatment like brackets, wires, molar band will be paid by the patient. If the patient will decide to discontinue the treatment, the patient must pay debonding and all orthodontic treatment phases that has been done already, except for the phases that has not been rendered.
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