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SureSmile® Informed Consent Form 

Congratulations on your decision to pursue orthodontic treatment for you or your child. SureSmile® Aligner is an excellent choice made by your care provider to create beautiful, new smiles. For optimal results, we require you to have seen a dentist and had an exam within the last 6 months. Please read the following information and make sure that you ask any questions or raise any concerns you may have before signing the consent agreement.

RISKS OF TREATMENT 

1) Failing to follow doctor instructions may interfere with achieving treatment objectives. This includes not wearing appliances as directed or missed appointments. All treatment times are estimated and may be extended by eruption of teeth or issues related to patient’s specific dentition, including uncommon tooth shape and any other anomaly encountered during treatment. 

2) Inadequate patient oral hygiene during treatment may result in decay, gum irritation, tissue disease or permanent discoloration of teeth. In the event that all hygiene instructions are not followed, including regular brushing/flossing and regular practice of standard oral hygiene, intraoral inflammation or gum disease may result. 

3) Minor discomfort when switching aligners during treatment is expected. However, any concern regarding pain or difficulty with placing a new appliance should be immediately reported to your care provider or staff. Patient may experience irritation to gums, cheeks or lips during treatment, which should also be communicated to care provider or staff. Allergic reactions are also possible and should be reported as well. 

4) Interproximal (space between the teeth) re-contouring or minor shaping may be required to allow space for teeth to move for proper alignment. 

5) Orthodontic treatment involves moving teeth and teeth may shift after treatment. Retainers must be worn at the direction of your care provider to control this tendency. In short, wearing retainer’s post-treatment is essential to maintaining your new smile. 

6) In some cases, additional treatment appliances may be required for treatment plans. Such supplemental clinical requirements will be explained by your care provider. These may include the need for oral surgery to correct jaw position or severe crowding, which must be completed prior to aligner treatment. 

7) Notify your care provider of any medical conditions/medications as they could affect treatment. 

8) Dental implants cannot be moved by aligners. Additionally, existing restorations may require repositioning or replacement as the result of treatment, which may require additional dental, surgical or endodontic treatment. In extreme cases, teeth may be lost. 

9) Orthodontic appliances can possibly be swallowed or aspirated. Any looseness of aligners or any other appliance used during treatment should be immediately reported to your care provider. In cases involving extreme crowding or missing teeth, product breakage is more common. 

10) Orthodontics is not an exact science, and I acknowledge that my care provider and Dentsply Sirona Inc. and its subsidiaries (collectively, “Dentsply Sirona”) have not and cannot make any guarantee or provide any other assurances regarding the outcome of any treatment. I understand that Dentsply Sirona is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give any medical advice. 

11) In signing this document, I am indicating that I understand the risks or options available for orthodontic treatment. Any concerns or questions that I may have had were sufficiently explained by my doctor and I consent to treatment for myself or a minor under my legal care. I also agree that the doctor my or a minor trustee under my care any medical records, including but not limited to, x-rays, reports, charts, medical history, photographs, findings, dental plaster models or impressions, diagnosis, prescriptions, testing and results, billing or any other records regarding treatment and in my care provider’s possession to other licensed dentists or orthodontists. I also agree that Dentsply Sirona, including but not limited to its employees or other representatives, successors, assigns and investigative agents for the purpose of investigating and reviewing of my or my minor trustee for any aspect of my medical history as pertaining to orthodontic treatment with Dentsply Sirona products or for educational or research purposes. 

12) I also understand the any use of my medical records may result in the disclosure of my or my minor trustee in disclosure of “individually identifiable health information” as defined by the Health Portability and Accountability Act (“HIPPA”). I will not, nor anyone acting on my behalf, seek legal, equitable or monetary damages or remedies for such disclosure. I understand that no compensation will be provided for use of my medical records, which is without compensation. I acknowledge that I as well as anyone on my behalf shall have any right of approval, claim of compensation or seek legal, equitable or monetary damages or remedies resulting from any use in compliance with this Consent’s terms. 

13) Should revisions and/or replacements be needed by fault of the patient, due to failure to wear aligners, loss, or ortherwise, a fee of AT LEAST $250 up to the total cost of the case my be required.

I understand that all deposits, partial payments and full payments are non-refundable.

I agree that I have read, understand and agree to terms stated in this Informed Consent Form as indicated my signature below; a photostatic copy of this Consent will be regarded as effective and valid as an original. 

 

First Patient's Name

First Name*

Middle Name

Last Name*

Phone*
First Patient's Date of Birth*
First Patient's Signature*
Second Patient's Name

First Name*

Middle Name

Last Name*
Second Patient's Date of Birth*
Third Patient's Name

First Name*

Middle Name

Last Name*
Third Patient's Date of Birth*
Fourth Patient's Name

First Name*

Middle Name

Last Name*
Fourth Patient's Date of Birth*
Fifth Patient's Name

First Name*

Middle Name

Last Name*
Fifth Patient's Date of Birth*
Sixth Patient's Name

First Name*

Middle Name

Last Name*
Sixth Patient's Date of Birth*
Seventh Patient's Name

First Name*

Middle Name

Last Name*
Seventh Patient's Date of Birth*
Eighth Patient's Name

First Name*

Middle Name

Last Name*
Eighth Patient's Date of Birth*
Ninth Patient's Name

First Name*

Middle Name

Last Name*
Ninth Patient's Date of Birth*
Tenth Patient's Name

First Name*

Middle Name

Last Name*
Tenth Patient's Date of Birth*
Parent or Guardian's Email Address

Email*

Confirm Email*
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How Did you hear about Build A Smile?
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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