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af0 \loch \f0 \ul1 ORTHODONTIC TREATMENT CONSENT FORM}{\b1 \fs32 \kerning2 \dbch \
af2 \hich \af0 \loch \f0 \ul1 \par }\pard \plain \qc \li0 \ri0 \lisb0 \lisa0 \
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fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 While recognizing the benefits of a
pleasing smile and healthy teeth, you should also be aware that orthodontic
treatment, like any treatment of the body, has some inherent risks and limitations.
These are seldom enough to contraindicate treatment, but should be considered in
making a decision to start orthodontics. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \
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\fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \
hich \af0 \loch \f0 The patient\uc1 \u8217 ?s responsibility:}{\fs24 \kerning2 \
dbch \af2 \hich \af0 \loch \f0 It is the patient\uc1 \u8217 ?s responsibility to
follow the brushing and oral hygiene instructions that are given, so that no harm
will come to the teeth and surrounding tissues; to come to all appointments on the
proper day and time; to adhere to the list of food restrictions in order to keep
from damaging the teeth and orthodontic appliance and retainers, if they are
necessary, so that treatment time will be as short as possible and so we can
achieve the best results. There will be additional orthodontic charges for
replacement of appliances (such as retainers or braces) that are lost or damaged
due to repeated patient neglect, or any excessive extension of treatment due to
lack of patient co-operation. 100% patient co-operation is very important. }{\
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loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Oral hygiene:}{\fs24
\kerning2 \dbch \af2 \hich \af0 \loch \f0 Decalcification (permanent markings),
decay, or gum disease can occur if patients do not brush their teeth properly and
thoroughly during treatment period. Excellent oral hygiene and plaque removal is a
must. Sugars and between meal snacks should be reduced as much as possible. }{\fs24
\kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \
lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \
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loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 A non-vital or dead
tooth is a possibility:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 A tooth
that has been traumatized from a deep filling or even a minor blow can die over a
long period of time with or without orthodontic treatment. An undetected non-vital
tooth may flare up during orthodontic movement, requiring endodontic (root canal)
treatment to maintain it. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\
pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \
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\dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \
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af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Root
resorption:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 In some cases, the
root ends of the teeth are shortened during treatment. This is called root
resorption. Under healthy circumstances the shortened roots are no disadvantage.
However, in the event of gum disease in later life the root resorption may reduce
the longevity of the affected teeth. It should be noted that not all root
resorption arises from orthodontic treatment. Trauma, cuts, impaction, endocrine
disorders, idiopathic reasons can also cause root resorption. }{\fs24 \kerning2 \
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fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \
hich \af0 \loch \f0 Growth issues:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0
Occasionally a person who has grown normally and in average proportions may not
continue to do so. If growth becomes disproportionate, the jaw relation can be
affected and original treatment objectives may have to be compromised. Skeletal
growth disharmony is a biologic process beyond the orthodontist\uc1 \u8217 ?s
control. Some orthodontic patients will require oral surgery to obtain a reasonable
treatment result to complete their case. Most patients we can inform ahead of time
prior to starting any treatment that this is necessary. Some patients with poor
growth, poor response to treatment, or poor co-operation may also require oral
surgery to complete their cases. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \
f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \
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b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Gum tissues:}{\fs24 \kerning2 \
dbch \af2 \hich \af0 \loch \f0 The bone-gum relationship around teeth is always
dependent upon whether there is enough bone to support the gum tissue properly.
Many times when very crowded teeth are straightened there is a lack of bone and
supporting gum tissues surrounding the teeth. Therefore, the gum tissue contour and
support may not be adequate and require periodontal intervention. }{\fs24 \kerning2
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af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\
pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \
lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\b1 \fs24 \
kerning2 \dbch \af2 \hich \af0 \loch \f0 Treatment time:}{\fs24 \kerning2 \dbch \
af2 \hich \af0 \loch \f0 The total time for treatment can be delayed beyond our
estimate. Lack of co\'02operation, broken appliances and missed appointments are
all important factors that could lengthen treatment time and affect the quality of
the result. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \
qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \
itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch \
af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \
widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \
af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0
TMJ:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 There is a risk that
problems may occur in the temporomandibular joints (TMJ). Although this is rare, it
is a possibility. Tooth alignment or bite correction sometimes can improve tooth
related causes of TMJ pain, but this in not in all cases. Tension appears to play a
role in the frequency and severity of joint pains, and there are many other causes
of TMJ dysfunction. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \
plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \
rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch
\af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar
\aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \
hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Very
unusual occurrences:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Swallowed
appliances, chipped teeth, dislodged restorations and allergies to latex or nickel
rarely occur but are possible. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \
par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \
adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\
fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \
lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \
kerning2 \dbch \af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \
af0 \loch \f0 Termination of treatment:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \
loch \f0 It is understood that treatment can be terminated for failure to
cooperate, missing appointments, not wearing appliances, excessive breakage,
failure to keep financial commitments, relocation, personal conflicts or for any
other reason the doctor feels necessary.}{\fs24 \kerning2 \dbch \af2 \hich \af0 \
loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \
aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \
loch \af0 {\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \
li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0
\fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \
hich \af0 \loch \f0 Expectations:}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0
All orthodontic patients can expect improvement with their particular problem, but,
in many cases, absolute perfection is impossible due to lack of muscle balance,
tooth shapes and sizes and varying degrees of co-operation during treatment, along
with heredity aspects that affects everyone\uc1 \u8217 ?s specific treatment
results. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \
li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0
\fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch \af2 \
hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \
aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \
af0 \loch \af0 {\b1 \fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Relapse:}{\fs24
\kerning2 \dbch \af2 \hich \af0 \loch \f0 Teeth have a tendency to return to their
original position after orthodontic treatment. This is called relapse. Very severe
problems have a higher tendency to relapse and the most common area for relapse is
the lower front teeth. After band removal, a positioner or retainers are placed to
minimize relapse. Full co-operation in wearing these appliances is vital. We will
make our correction to the highest standards and in many cases over correct in
order to accommodate the rebound tendencies. When retention is discontinued some
relapse is still possible. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \
par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \
adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\
fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \
lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \
kerning2 \dbch \af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch \af2 \hich \af0 \
loch \f0 I consent to the taking of photographs, study models and x-rays before,
during and after orthodontic treatment to assist in the planning and progress
treatment objectives. If the case proves to be of special scientific interest, the
dentist reserves the right to present the records in scientific papers or
demonstrations to the profession. I certify that I have read or had read to me the
contents of this form and do realize the risks and limitations involved, and
consent to orthodontic treatment. }{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0
\par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \aspnum \
adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \loch \af0 {\
fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \par }\pard \plain \qj \li0 \ri0 \
lisb0 \lisa0 \widctlpar \aspalpha \aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \
kerning2 \dbch \af2 \hich \af0 \loch \af0 {\fs24 \kerning2 \dbch \af2 \hich \af0 \
loch \f0 \par }\pard \plain \qj \li0 \ri0 \lisb0 \lisa0 \widctlpar \aspalpha \
aspnum \adjustright \lin0 \rin0 \itap0 \fs21 \kerning2 \dbch \af2 \hich \af0 \
loch \af0 {\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Dat}{\fs24 \kerning2 \
dbch \af2 \hich \af0 \loch \f0 \lang16393 \langnp16393 e
}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 Patient/Parent/Guardian Signature
}{\fs24 \kerning2 \dbch \af2 \hich \af0 \loch \f0 \lang16393 \langnp16393 \par }}