Orthodontic Contract and Consent Form PDF
Orthodontic Contract and Consent Form PDF
I. The Orthodontic Treatment Package (OTP) shall be determined by the dentist/ orthodontist/ doctor. Prices may vary due to
the nature of each patient’s case.
II. Cost of orthodontic package: _______________________
Initial down payment: _______________________
Monthly Installment: _______________________
Estimated Duration of Treatment: 2 - 3 years (+/-)
III. The orthodontic package will include all costs of the material needed for the patient’s case, dentist/orthodontist/ doctor’s
professional fees and all other expenses, fees and charges necessary for or incidental to the specific treatment.
IV. All minor patients must have written consent from parents or guardians before treatment commences.
V. Payment of the orthodontic package fees shall be made on a MONTHLY basis. If a patient fails to pay on the specific monthly
visit, it is understood that such payment must be settled on the patient’s next visit.
VI. Prices/costs shall be kept confidential at all times, even after the termination of the doctor-patient relationship.
VII. The Orthodontic Package Fee should be settled upon the completion of treatment.
INCLUSIONS
I. Oral prophylaxis (cleaning), every (3) months during the orthodontic treatment and free (3) restoration/pasta.
II. Gum treatment for orthodontic gingivitis and mouth sores.
III. Retainers if (you could refer 3 patients)
NON-INCLUSIONS
All standard rates apply hereafter; however, discounts may be given at the discretion of the dentist/ orthodontist/ doctor.
TERMS AND CONDITIONS
I. The clinic follows a strict rule of “FIRST COME FIRST SERVE WITH APPOINTMENT” rules. Clinic only accepts patient for
adjustment on an appointment basis.
II. The clinic strictly follows the CHART TIME RULE. This is determined based on how many times the patient comes in for the
treatment; the clinic does not use CALENDAR TIME in determining treatment duration.
III. Four (4) months or more of non-appearance and treatment, despite repetitive reminders from the clinic, we entitle the clinic
to automatically put the patient’s case in our dormant file. No notices will be sent afterwards. No paid fees shall be refunded.
IV. The clinic reserves the right not to accept delinquent patients of four (4) months or more and will result to termination of
contract. No paid fees shall be refunded.
V. The patient must advise the dentist of any temporary cessation of treatment due to illness, pregnancy or any other health
conditions prior to the next scheduled appointment. Failure to notify the dentist and to keep the appointment by appearing at
the clinic for treatment shall result in an additional 10% of cost of the package, which shall be collected upon resumption of
treatment.
VI. However, if a patient notifies the clinic of the above-mentioned circumstances, treatment and payment of fees shall resume
and NO ADDITIONAL FEES SHALL BE COLLECTED.
VII. In all cases of the above mentioned the dentist WILL NOT BE HELD LIABLE FOR WHATEVER CONSEQUENCES THAT MAY ARISE
DUE TO NON-APPEARANCE OF THE PATIENT FOR THE TREATMENT.
VII. There shall be NO REFUND of fees that already paid for.
IX. There shall be NO REFUND OF FEES for patients who wish to pre-terminate treatment and contract for whatever reason. Patient
shall have to pay the running cost incurred by the dentist at the time of pre-termination. The dentist shall present to the patient
the calculated cost upon patient’s request. The dentist shall not be held liable to any consequences that may arise from pre-
termination.
X. NO release of diagnostic aids (panoramic, periapical, cephalometric radiographs) working study casts and patient chart during
and after the treatment.
XI. The clinic and/or dentist reserves the right to refuse treatment to an individual who is unruly in behaviour. Moreover, the clinic
and/or dentist reserves the right to pre-terminate the contract if the patient is proven to be uncooperative with respect of the
treatment and unruly in behaviour. The clinic and/or the dentist shall be indemnified of any and all claims made by the patient
and any and all expenses in relation therewith, such as, limited damages suffered, costs incurred in consulting with other
dentist and legal expenses as a result of pre-termination of treatment.
XII. If the patient intends to leave for other country or migrate to other country while still undergoing treatment, the patient shall
advise the clinic and/or dentist of his/her intentions. The patient should make arrangements with the clinic. Minimum fee
would be charged to the patient based on his/her balance from the OTP. No records shall be released except for the patient’s
profile.
XIII. The dentist/orthodontist shall not be liable for relapse of any dental condition, whether or not covered by the OTP, for which
the patient has sought any treatment.
XIV. Lost, misplaced, damaged brackets, wires, molar bands and tubes shall be charged to the patient.
XV. Patients who wish to have their appliance removed temporarily for an occasion will be charged with a minimum fee for both
REMOVAL AND RE-INSTALLATION. The clinic/dentist DO NOT USE THE SAME FOR REINSTALLATION.
INFORMED CONSENT FOR THE ORTHODONTIC PATIENT
Risks and Limitations of Orthodontic Treatment
I. RESULTS OF TREATMENT
Orthodontic treatment proceeds relative to the treatment plan, and we intend to do everything possible to
achieve the best results for every patient. Nevertheless, we cannot guarantee that you will be completely
satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment
depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or
broken appliances, and following the clinician's instructions carefully.
III. DISCOMFORT
The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the
introduction of orthodontic appliances. Nonprescription pain medication can be used during this adjustment
period.
IV. RELAPSE
Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers
will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must
wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear
is often necessary for several years following orthodontic treatment. However, changes after that time can
occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and
maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities,
particularly in the lower front teeth, may have to be accepted. Some changes may require additional
orthodontic treatment or, in some cases, surgery. Some situations may require non-movable retainers or other
appliances made by the dentist.
V. EXTRACTIONS
Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks
associated with the removal of teeth which you should discuss with the dentist or oral surgeon prior to the
procedure.
X. PERIODONTAL DISEASE
Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors,
but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a
periodontist monitors your periodontal health during orthodontic treatment every three to six months. If
periodontal problems cannot be controlled, treatment may have to be discontinued prior to completion.
XVII. ALLERGIES
Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This
may require a change in treatment plan or discontinuance of treatment prior to completion. Although very
uncommon, medical management of dental material allergies may be necessary.
I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in
this form. I also understand that there may be other problems that occurs less frequently than those presented, and that
actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the attending
dentist and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment.
I hereby consent to the treatment proposed and authorize the attending dentist to provide the treatment. I understand
that my treatment fee covers only treatment provided by the dentist and that treatment provided by other dental or
medical professionals is not included in the fee for my orthodontic treatment.
______________________________________
Signature over Printed name
________________________________________ _______________________________________
Dr._________________________, DMD Signature over Printed Name of Guardian if
DENTIST patient is minor & date