Consent to orthodontic treatment

I hereby authorize Dr._____________________________ to complete orthodontic treatment

for/myself/child ___________________(print patient's name).

I have been told that the success for the treatment depends upon several factors under my and my
patients control, such as: following recommended oral hygiene procedures, diet, and nutrition, home
care advice, cooperation with maintaining the appliance and keeping office appointments.

I understand that regular dental examinations by our family dentist are essential to the success of the
orthodontic treatment. In addition, referrals to the other dental specialists may be required, e.g., a
periodontist or an oral surgeon. I further understand that despite all estimates of the success of the
treatment, there are many personal biologic factors that cannot be predicted in advance that may affect
its success.

I have been informed that one of the complications of orthodontic treatment may be problems
associated with the temporomandibular joint. this is the joint located in front of each ear and connects
the lower jaw to the skull. if there is any discomfort in the joint during treatment I am to report it to the
dentist as soon as possible. I understand that if this occurs further consultation and treatment may be
necessary.

I understand that following completion of treatment retaining device may be necessary to maintain the
position of the corrected bite. Also that some grinding, reshaping and extraction of the teeth may be
necessary to adjust the bite and occlusion.

I have discussed all the above with the doctor, all my questions have been answer, and i fully
understand why the orthodontic treatment is necessary, its limitation, estimated of success, and the
dental health effects for refusing to accept the recommended care. I understand that individual
reactions to treatment cannot be predicted, and that id I experience any reactions following treatment, I
agree to report them to the office as soon as possible.

I have been told that success of the treatment depends upon my cooperation in keeping scheduled
appointment, following home care instructions and reporting to the office any changes in my health
status. I acknowledge that no guarantees or assurance have been given by anyone regarding results that
my be obtained. I also understand that if I have questions regarding the treatment I am to ask the
doctor prior to signing this consent

I understand and agree to the professional fee amounting to P__________________

Other concerns:

Patient's signature(or Responsible party)

Date