Healthcare Orthodontics Consent Form

HEALTHCARE ORTHODONTICS CONSENT FORM

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical History

Are you pregnant or nursing?   Yes   No

Do you have a history of cardiac conditions, bleeding disorders, or a pacemaker?   Yes   No

Procedure Description and Consent

I authorize the orthodontic provider and clinical staff to perform the following diagnostic, preventive and corrective procedures as indicated and explained to me:

Anticipated start date:

Risks, Complications, and Benefits

The practice has explained to me the nature and purpose of the proposed orthodontic treatment, and the anticipated benefits (improved dental alignment, function, and esthetics). I understand that no guarantee of specific results has been made. The commonly known risks and potential complications include, without limitation: tooth mobility, tooth sensitivity, root shortening (root resorption), relapse following treatment, periodontal (gum) changes including gum recession and bone loss, caries if oral hygiene is inadequate, allergic reactions to materials, pain or discomfort, failure to achieve desired occlusion or esthetic result, need for additional corrective procedures or extraction of teeth, and in rare cases, temporomandibular joint (TMJ) symptoms or need for referral for surgical management.

I acknowledge that I have discussed the risks and benefits with my provider and have had the opportunity to ask questions. I understand that unforeseen conditions may require modification or extension of the planned treatment.

I acknowledge that the risks and benefits of the proposed orthodontic treatment have been explained to me and that I understand them.

Alternative Treatments & Right to Withdraw

Alternative options, including no treatment, monitoring, removable appliances or surgical approaches, have been discussed as appropriate. I understand I may refuse or withdraw consent for treatment at any time; however, discontinuing treatment may negatively affect the outcome and could require additional procedures to restore function or esthetics.

I acknowledge that alternatives were discussed and that I understand my right to withdraw consent.

Photographs, Records, and Use of Information

I authorize the taking of clinical photographs, radiographs and dental impressions as needed for diagnosis, treatment planning, and progress records. I consent to the use of de-identified clinical records for education, quality assurance, and publication unless I specifically revoke that authorization below.

I consent to clinical photographs and records for treatment and professional education.

Financial Responsibility

I understand that I am financially responsible for charges for services rendered. I authorize assignment of benefits to the provider and authorize release of information necessary to process insurance claims. I acknowledge that the provider's estimate of insurance coverage is not a guarantee of payment and that I remain responsible for unpaid balances, co-payments, deductibles, and non-covered services.

I accept financial responsibility and authorize billing to my insurance where applicable.

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices that describes how my medical and dental information may be used and disclosed. I understand my rights with respect to my protected health information and that I may request restrictions on certain uses and disclosures.

I acknowledge that I have received and reviewed the privacy notice.

Authorization to Release Records

I authorize the release of my orthodontic records, including radiographs and clinical photographs, to the following recipient for treatment, insurance, or continuity of care:

Authorization Expiration Date:

Certifications and Signature

By signing below I certify that I have read and understand this consent form, that the information I have provided on this form is accurate to the best of my knowledge, that the procedure(s), risks, benefits and alternatives have been explained to me, and that all my questions have been answered to my satisfaction. I hereby consent to the orthodontic treatment and related procedures described above and authorize the use and disclosure of my dental and medical information as set forth in this form.

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