Healthcare Aligners Form

HEALTHCARE ALIGNERS FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Medical & Dental History

Please answer all applicable items. Omissions may affect treatment outcome and liability for costs.

Do you use tobacco products? Yes No

For female patients: Are you pregnant or planning pregnancy during treatment? Yes No

Do you have any of the following? (check all that apply) Cardiac pacemaker or implant Current or prior bisphosphonate therapy Bleeding disorder

Treatment Plan & Consent for Aligner Therapy

Estimated duration of active aligner therapy:    Expected number of aligner sets:

Risks and complications that may arise from aligner therapy include, but are not limited to: root resorption, tooth mobility, relapse, bite changes, occlusal interferences, need for adjunctive procedures (extractions, interproximal reduction), temporomandibular joint discomfort, tooth sensitivity, allergic reaction to materials, and periodontal issues. There is no guarantee that treatment objectives will be fully achieved.

I acknowledge that my treating clinician has explained the nature of aligner therapy, the anticipated benefits, and the material risks and alternatives, including the option of no treatment or alternative orthodontic/orthopedic modalities.

I understand that active cooperation is required (wearing aligners as prescribed, maintaining oral hygiene, attending scheduled appointments). Failure to comply may affect outcomes and may result in additional fees for remedial care.

Acknowledge consent and understanding: I have read and understand the above and consent to aligner therapy.

Photography, Records & Release

I authorize the taking of photographs, radiographs, digital scans, and impressions necessary for diagnosis, treatment planning, progress records, and public health reporting as required. I understand such records are part of my medical record.

I authorize release of treatment information and records to insurance carriers, other treating clinicians, and laboratories for the purposes of claims processing and coordination of care.

Financial Responsibility & Insurance Assignment

I authorize the practice to submit claims to my insurance carrier and to apply insurance payments to my account. I assign benefits payable for services rendered to the treating practice to the extent permitted by law. I remain financially responsible for all charges not covered by insurance, including co-payments, deductibles, and services denied by my insurer.

I understand that payment arrangements, refunds, and finance policies have been provided and that failure to pay may result in collection action. I acknowledge financial responsibility.

HIPAA & Privacy Acknowledgment

I have received or been offered a notice describing how my protected health information may be used and disclosed and how I can access this information. I understand the practice's duties to protect my privacy and my rights with respect to my health information.

I acknowledge receipt of the Privacy Practices notice and consent to the use of my health information for treatment, payment, and healthcare operations as described therein.

Emergency Treatment Authorization

In the event of an emergency occurring during treatment, I authorize necessary emergency dental care including local anesthesia, and I consent to referral for medical treatment if necessary.

I authorize emergency treatment as described above.

Certifications & Acknowledgments

I certify that the information I have provided on this form is complete and true to the best of my knowledge. I understand that withholding information or providing false information may adversely affect treatment and relieve the treating clinician of certain responsibilities.

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