Healthcare Invisalign Consent Form

Healthcare Invisalign Consent Form

Patient Information

Male Female Other / Prefer not to say

Insurance Information

Medical & Dental History

Please describe current medications, including dosage and frequency:

Known allergies (medication, latex, metals, adhesives, etc.):

Prior dental surgeries or orthodontic treatment:

Chronic medical conditions (diabetes, autoimmune disease, bleeding disorders, etc.):

Treatment Description

Invisalign clear aligner therapy is an orthodontic system using a series of removable, custom-fitted thermoplastic aligners to move teeth incrementally. Treatment may include attachments bonded to teeth, interproximal reduction (IPR) to reshape tooth surfaces, and the use of elastics or auxiliaries when indicated. The estimated duration of active aligner therapy is months, subject to clinical change.

Select any procedures that may be performed as part of the treatment plan:

Bonding of composite attachments to teeth for aligner retention
Interproximal reduction (IPR) / enamel reshaping
Use of elastics or auxiliaries
Post-treatment refinements (additional aligners) may be required

Risks, Potential Complications and Acknowledgements

I acknowledge that my practitioner has explained the nature of Invisalign treatment, its expected benefits, reasonable alternatives (including no treatment, braces, or other appliances), and the material risks and potential complications associated with treatment, including but not limited to the following. I understand that not all risks can be listed.

Tooth and/or root sensitivity, transient or chronic, including increased sensitivity to cold, heat, biting or percussion.
Soft tissue irritation, ulceration or soreness from aligners, attachments, or elastics.
Root resorption (shortening of tooth roots) which may be permanent and could affect tooth stability.
Possible need for endodontic treatment (root canal) or extraction in rare cases.
Temporomandibular joint (TMJ) discomfort, pain, or dysfunction may occur or be aggravated.
Relapse or movement after treatment if retainers are not worn as instructed; long-term retention typically required.
Unpredictable tooth movements or incomplete correction requiring additional treatment or refinements.
Allergic or adverse reactions to aligner materials, bonding agents or metals used in adjunctive appliances.

I understand that successful treatment requires compliance with wearing aligners as instructed, attending scheduled appointments, and following home care instructions. Failure to comply may prolong treatment time, increase costs, and reduce the likelihood of achieving the planned outcome.

HIPAA/Privacy & Authorization

I authorize the release and disclosure of my dental and medical records, including diagnostic records, dental models, photographs, radiographs and treatment notes, to the treating clinicians, the dental laboratory, and other healthcare professionals as necessary to provide and coordinate my care. I understand that this authorization is voluntary and that I may revoke it in writing, except to the extent that action has already been taken pursuant to this authorization.

I acknowledge receipt of the practice privacy policy and authorize release of information as described above.

Financial Responsibility & Other Terms

I acknowledge that I am financially responsible for all fees associated with the proposed treatment program regardless of insurance coverage. I understand that additional charges may apply for attachments, IPR, refinements, missed appointments, or restorative work necessary to achieve treatment goals. The clinician has not guaranteed a cure or complete correction of orthodontic problems.

I have had the opportunity to ask questions and have received satisfactory answers about the proposed treatment, alternatives, anticipated results, risks and potential complications. I understand that I may withdraw consent at any time prior to or during active treatment by notifying the treating clinician, although withdrawal may not relieve me of financial responsibility for services already rendered.

Minor Consent (if applicable)

Patient is a minor and the following parent/guardian is providing consent:

Consent and Signature

By signing below, I certify that I have read and understand this consent form, that the information I provided is accurate to the best of my knowledge, that the nature of the proposed Invisalign treatment has been explained to me including expected benefits, alternative options, and material risks, and that I consent to receive the described treatment and associated diagnostic procedures.

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