Orthodontic Treatment Agreement and Informed Consent

Patient Information

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

1. Treatment Understanding

• I understand that orthodontic treatment involves wearing appliances (braces, aligners, etc.) as prescribed
• The estimated treatment duration is _____ months, but may vary based on individual response
• I acknowledge that perfect results cannot be guaranteed

2. Patient Responsibilities

Appointments

• Maintain regular appointments as scheduled
• Provide 24-hour notice for cancellations
• Understand that missed appointments may extend treatment time

Home Care

• Follow all dietary restrictions
• Maintain excellent oral hygiene
• Wear elastics and other appliances as directed
• Report any broken appliances promptly

3. Financial Agreement

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

4. Risks and Limitations

• Root resorption
• Decalcification if oral hygiene is poor
• Temporary discomfort
• Potential relapse without proper retainer wear

5. Retention Phase

• Wear retainers as prescribed
• Regular retainer checks required
• Additional fees may apply for replacement retainers

Signatures

Patient/Guardian: _________________ Date: _______ Orthodontist: _________________ Date: _______ Witness: _________________ Date: _______