Orthodontic Treatment Agreement and Informed Consent

Patient Information

Patient Name: _________________________ Date of Birth: _________________________ Parent/Guardian (if minor): _________________________

1. Treatment Overview

I, _________________________, hereby consent to orthodontic treatment provided by Dr. _________________________ and staff at _________________________ ("Practice").

2. Treatment Procedures

• Installation and adjustment of orthodontic appliances
• Regular monitoring of tooth movement
• Placement and removal of separators, bands, brackets, and wires
• Additional procedures as deemed necessary for treatment

3. Treatment Duration and Compliance

• Estimated treatment duration: _______ to _______ months
• Regular appointments every _______ weeks
• Patient compliance requirements:
  • Wearing appliances as directed
  • Maintaining proper oral hygiene
  • Following dietary restrictions
  • Keeping scheduled appointments

4. Financial Agreement

• Total treatment fee: $_____________
• Initial payment: $_____________
• Monthly payment amount: $_____________
• Insurance coverage (if applicable): $_____________

5. Risks and Limitations

• Root resorption
• Decalcification
• TMJ complications
• Relapse potential
• Treatment time variations

6. Post-Treatment Responsibilities

• Retention protocol
• Follow-up visits
• Maintenance requirements

7. Acknowledgment

I have read and understand this agreement and have had all my questions answered satisfactorily.

Signature: _________________________ Date: _________________________

Practitioner Signature: _________________________ Date: _________________________