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Insurance claims will be billed for your convenience.
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If for any reason insurance does not pay their estimated mount, the patient becomes responsible for the remaining balance.
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This include loss of benefits or coverage, delay in payments (60 days) , or pre-determinations.
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Insurance estimates are not a guarantee of payment. |
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Benefit elections are not a guarantee of payment. |
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Benefit elections are handled between you, your insurance company, and your employer
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If your benefit were based on discounted fees or a discount off our usual fee and coverage is lost, your account will be recalculated based on
our current cash pricing, or new benefits will be considered. |
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Before beginning orthodontic treatment, you should be aware there are inherent risks and limitations. These are seldom enough to rule out treatment.
but should be carefully considered before deciding to begin orthodontic treatment. Please note that it is impossible to list. Every possible
circumstance and the following must be considered a patient list. Please read this consent carefully and ask for an explanation of any you do
not understand. A certain amount should be expected when braces are put on and at each wire change.
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Treatment Process It is impossible to predict the amount of time each patient’s treatment will require. Lack of facial growth, gum disease,
poor corporation, missed appointments, and broken appliances are most common contributing factors.
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(Initials)
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Removal of Teeth sometimes teeth must be extracted as part of the orthodontic process. This will be based on the orthodontist’s
judgment of the case. Such removal may include, but is not limited to, third molars (wisdom teeth) or bicuspids and will not be done by the
orthodontist, but by a general dentist or oral surgeon as deemed necessary and is not included orthodontic treatment fee.
If you refuse extractions and it subsequently becomes necessary (due to poor results) to extract teeth originally diagnosed for extraction,
the entire case will be considered a ‘Re-start’ and will be charged as entirely new treatment at full. Do not have any extractions or have
bridges placed without consulting your orthodontist.
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(Initials)
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Late Growth Changes If growth becomes disproportionate. The jaw relationship can be seriously affected and original treatment
objectives may not be met.
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(Initials)
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Additional Treatment unforeseen circumstance (growth changes, late extractions, gum disease, act.) may result in a form of
treatment not previously discussed. If this occurs, the reasons for the change in treatment and any additional fees will be carefully explained
before proceeding.
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(Initials)
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Success of Treatment we cannot guarantee the proposed treatment plan will be successful or to your complete satisfaction.
Due to individual patient differences, there exists the possibility of failure, relapse or selective re-treatment, despite the best of case.
Much of the success of treatment depends on the understanding and cooperation of the patient. Appointments must be kept as scheduled, appliances,
and headgear must be worn as directed and good oral hygiene must be maintained.
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(Initials)
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TMJ Pain patients may suffer from noise or pain near the ear in the joint (TMJ) of the lower jaw as the bite is changed.
Depending upon the severity of my condition. I may be referred to a dentist who specializes in TMJ treatment. the cost of which is my
responsibility.
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(Initials)
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Injury from Appliances Headgear instructions must be carefully followed. Brackets and wires can be dislodged or broken and
can be swallowed or inhales. The risk is increased when the patient ignores advice and recommendations. Occasionally dental instruments may poke,
scratch or cause a blow to the tooth with potential damage or soreness to oral structures.
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(Initials)
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Devitalization It is possible for a tooth to die during orthodontic treatment, especially if it was previously injured or
traumatized. Such previous injures cannot be detected by the orthodontic. Rool canal therapy may be recommended in such cases. Teeth which
have been previously treated endodontically, may become symptomatic and any additional treatment is the patient’s responsibility.
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(Initials)
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Miscellaneous ConditionsDecalcification, decay. Gum disease, mletion, etching, pain, swelling, tooth semiwet, mobility, gum
and bone recession are some problems which may occur if the patient does not cooperate with brushing or flossing and have regular checkups with
thee general dentist. Cleaning and cavity clearance are required every six months during orthodontic treatment. Proper dietary control is essential.
If periodontal disease occurs during the course of treatment. If may be difficult or impossible to control the loss bone and subsequent loss of
teeth. Orthodontic may aggravate a preexisting periodontal condition. When the case is complete and the patient is ready for dabanding. It is
impossible to determine if filling tooth structure may be damaged during routine dabaning. The patient is responsible for any restorations after
or due orthodontic treatment or debanding.
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(Initials)
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Ceramic /Metal brackets Some patients experience bracket breakage and or damage to teeth. If brackets fracture outside of the
office, it may result in sharp edges. Which might be harmful to the patient. Also, these brackets may cause enamel flaking and or enamel fracturing
on brand removal.
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(Initials)
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Root Resorption Shortening of root ends can occur when teeth are moved during orthodontic treatment especially in open bile/under
cases. Under healthy conditions, the shortened roots are usually not a problem. Trauma impaction, endocrine disorders or idiopathic (unknown)
reasons also cause this problem. Severe resorption can increase the possibility of premature tooth loss.
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(Initials)
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Orthodontic Surgery Cases (orthognathic) Many complex factors influence the course of treatment and it is possible in
certain cases that law modification surgery may be required at any phase during treatment. It is understood you have the choice to discontinue
(deband)or be referred to another orthodontist to treat the surgical phase of the case.
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(Initials)
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Relapse Any orthodontist corrections will be made following the highest standards: however, unless the patient carefully
follows retention instructions, relapse may occur. Lost or broken retainers should be replaced immediately.
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(Initials)
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Periodontal Disease understands that inflammation of the gum and loss of bone, known as periodontal disease, can develop
during orthodontic treatment due to many factors but most commonly due to inadequate oral hygiene and the difficulty of cleaning around
orthodontic appliance. Therefore, periodic examinations and necessary cleanings are required a minimum of every six months at my general dentist.
Depending upon the severity of my condition. I may be referred to a periodontal specialist for evaluation and treatment and as a result. Orthodontic
treatment may have to be suspended or terminated. Cleanings and periodontal treatment are not included in my initial fee for orthodontics and the
cost of which is my responsibly.
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(Initials)
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Impacted Cuspids In attempting to move impacted teeth (teeth unable to come in normally), especially cupids (eye teeth)
various problems are sometimes uncounted which may lead to periodontal problems, loss of tooth vitality (dead teeth), andiron complete loss of the
tooth.
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(Initials)
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