Patient Agreement and Informed Consent for Cosmetically Focused Tooth Alignment

This Patient Agreement contains important information about your treatment. BY SIGNING THIS PATIENT AGREEMENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. Please read carefully and ask questions about any areas that are unclear:

Scope of Treatment: Our objective is to straighten your teeth, usually without significant bite change, in a reasonable time frame-usually 4-9 months. You may have aspects of your bite that will not be addressed with this treatment, such as, but not limited to, molar relationships/posterior cross bite, overjet, underjet, facial profile, TMJ problems, displaced tooth roots and midline discrepancies. Full correction of the items mentioned here can often involve years of orthodontic treatment. The goal of this cosmetically focused and short-term orthodontic treatment is to correct your chief cosmetic complaints, which you have shared with us. This treatment is not a replacement for traditional comprehensive orthodontic treatment. This cosmetically focused treatment is an alternative for people who are not interested in traditional comprehensive orthodontic treatment and are seeking a more cosmetically focused orthodontic treatment option that can be provided over a shorter period of time.
Hygiene: BRUSH YOUR TEETH, GUMS, braces and wires thoroughly after each meal and before going to bed. Poor oral hygiene can result in puffy, bleeding gums and permanent white spots on teeth. INFLAMMATION AND BLEEDING GUMS WILL DELAY YOUR TREATMENT. An interproximal brush is the best way to clean around your braces
and can be purchased in any supermarket. Use this brush between your teeth at the gumline. We do reserve the right to suspend or delay treatment if your oral hygiene is poor. Keep your teeth and braces clean!
Hard Food: DO NOT EAT hard foods such as popcorn, ice, sticky or hard sweets. These foods can break the brackets. CUT UP foods such as meats, apples, carrots etc. before eating them. (If abuse is noted on multiple periodic treatment visits, a fee of £50 can be assessed.)
Soreness: After the braces are put on, the teeth may be sore, usually for 2-4 weeks. Paracetamol or ibuprofen may be taken to relieve this. If the soreness prohibits eating even soft food, please phone for an appointment so any necessary adjustments may be made. If the inside of the lips are sore, the wax that is provided can be used as a cushion over the braces until the lips become accustomed. Taking pain medication prior to your adjustment appointments can help minimise discomfort.
Jaw Joint: There are some patients who will develop a popping/clicking or other problems in their jaw joint during or after orthodontic treatment. This is very rare. Usually, orthodontic treatment provides a positive effect on the jaw joint. You should understand that pre-existing joint conditions can manifest as a popping or clicking after orthodontic treatment but orthodontic treatment by itself has not been shown to cause popping/clicking of the jaw joints.
Main Objective: I understand that the main objective of my orthodontic treatment is to align my teeth for cosmetic reasons. My bite and the relationship of my back teeth are not the focus of this treatment. 3-6 months may be required after treatment for the bite to settle and be completely comfortable. Significant changes in lip profile necessitate jaw surgery, which I am not seeking. I am aware of these objectives and limitations of short-term treatment. I fully understand that my course of treatment may not result in complete orthodontic correction. This is not mainstream orthodontic treatment philosophy and many orthodontists will disagree with this type of orthodontic treatment that does not aim to completely correct/change the bite relationship.

Technique: Space will be made by enamel reproximation (minor tooth reduction). This allows limited tooth movement in the area of the crowding. Rarely sensitivity is possible from this, but is transient and not common. Alternative treatment options to enamel reproximation for making space include tooth extraction, which we only perform in extreme cases of crowding, and expanding the dental arch is proven to be unstable in adult patients. Upper and lower dental midlines will not be made to coincide for most cases as midline changes often require years of treatment. Misshaped and abnormally long teeth will be reshaped as part of treatment. On occasion, bonding may be needed to provide an even appearance of the edges of front teeth whether because of stubborn tooth movement or misshaped teeth. Charges for bonding will be determined on a case-by-case basis.
Standard of Straightness: We seek to straighten teeth to a very high level with cosmetically focused orthodontic treatment. If, however, numerous custom requests arise which the doctor feels will take an inordinate amount of extra time or in fact may not even be possible to achieve, we reserve the right to refer you to an orthodontic specialist for conventional comprehensive, 2 year, bite- changing orthodontic treatment, without a refund of monies paid up until that point in treatment.
Retention: Teeth have a tendency to rebound to their original positions after orthodontic treatment. Very severe problems have a higher tendency to relapse, and the most common type of relapse occurs with twisted teeth. Retainers will be placed immediately to minimise relapse. Full cooperation in wearing these appliances (full time for 6 months, at night for 6 months, and every other night indefinitely) is essential and part time wear is required for years. There is a fee to replace lost retainers. There are both fixed and removable options for orthodontic retainers.
Disputes: Should any dispute arise regarding fees, treatment, its outcome, or other matters associated with treatment, I agree to seek resolution through arbitration (peer review process) in lieu of court in order to seek a speedy and fair resolution of such issues. By signing this consent form I am agreeing to handle any dispute that might arise as a result of treatment through a dental peer review process (arbitration).
Cleanings: You should have at least one professional cleaning during your treatment. If you have an appointment for a cleaning scheduled, keep it! This is not required but highly encouraged.
Appointments: Please keep your adjustment appointments! Missed appointments can result in delayed completion. Please notify us at least 48 hours in advance should you need to reschedule since another patient may need this time slot. There can be a fee assessed for all broken appointments or short notice cancels. (£30) There are some visits that are required after your braces are off (retainer checks etc.). These visits are very important. Relapse, bite settling, and retainer or splint adjustments (or breakage) are just some of the items we wish to monitor in this stage.
Moving: If you plan on moving during orthodontic treatment, it is usually advisable to complete treatment with our office. It would be difficult to change dentists during treatment.
Disclaimer and Release of Liability: I understand that the dentist who is providing my cosmetic tooth alignment is a general dentist and not an orthodontist. Whilst the dentist providing treatment has received further training to be able to provide this service it is not to the same level as an orthodontist.
I HAVE READ THIS PATIENT AGREEMENT AND FULLY UNDERSTAND ITS TERMS.

Financial Agreement

The fee for orthodontic treatment is:

Single arch £995

Full mouth £1595

 

This includes x-rays, consultation, photographs, study models, all visits, clear braces, tooth coloured wires, fixed retainers and clear plastic removable retainers.

 

Additional treatments which will only be added if completely necessary or selected by you. You will be informed at your consultation if these are of benefit:

 

• Expansion device (for narrow arches) £400
• TAD anchorage device each £400
• Digital scan (avoids returning to the clinic if plastic retainers are lost) £50

 

 

Alternatively, payment can be made in instalments, 10% per monthly visit so long as payment is completed before treatment.

 

We require a £200 deposit to secure the initial braces fit appointment.

I hereby agree to the terms of this agreement. I understand the financial decision I have made and I commit to make the appropriate payments. If I have chosen to make payments at each visit, I agree to pay the appropriate amount at the time of each visit.

Care and maintenance instructions for braces

WHAT TO EXPECT DURING TREATMENT
Your teeth and lips might be sore for about 1-2 weeks. If soreness persists you should contact us.
If you have BITE GUARDS placed on your teeth (most patients) you will only be able to bite on the bite guards. Your other teeth will not touch until about 2-4 months into treatment. You will get used to eating with the BITE GUARDS eventually.
You can use soft wax and pain killers to help aid with discomfort as needed. During the first few weeks, you can place the soft wax provided on parts of the braces that may be bothering you (wires or brackets).

IF ONE OF THE BRACES (BRACKETS) COME OFF
We want the braces to stay on your teeth. If one pops off your tooth, it will sometimes come out of your mouth and it will sometimes stay on the wire. If the dislodged brace (bracket) isn’t hurting you, try to hang on to it until you come in for your next adjustment.
You are responsible for safeguarding the brackets on your teeth.

AVOID THE FOLLOWING FOODS
Crusts, nuts, bagels, chicken wings, popcorn, raw vegetables, whole fruit, toffee and ANY OTHER FOOD THAT COULD DISLODGE YOUR BRACKETS. Spaghetti sauce, red wine, coffee, tea, strawberries, blue berries, curry, dark sauces, red juices and other highly coloured foods/drinks can stain your braces. Try to limit them.

BRUSH AND FLOSS YOUR TEETH
It is your responsibility to keep your teeth and braces clean.
Your adjustments will be easier if your teeth are clean.
Flossing can be difficult. So we recommend use of TePE brushes to clean in between your teeth.

Please call 0141 552 8898 if you have questions that are not answered on this form. We are here to help you.