Orthodontic Treatment Authorization and Consent Form

Patient Information

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

Treatment Authorization

I, the undersigned patient/parent/guardian, authorize Dr. _________________ and staff to perform orthodontic treatment including, but not limited to:

• Installation and adjustment of orthodontic appliances
• Placement of spacers, bands, brackets, and wires
• Taking of dental impressions, X-rays, and photographs
• Other necessary procedures for orthodontic treatment

Understanding of Treatment

I understand that:

1. The length of treatment depends on:

   • Patient cooperation
   • Regular appointment attendance
   • Growth and biological response
   • Complexity of the case

2. Potential risks include:

   • Decalcification and decay if proper oral hygiene is not maintained
   • Root shortening (resorption)
   • Periodontal/gum problems
   • Discomfort during treatment

Financial Agreement

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

Consent

I have read and understand the above information. My questions have been answered to my satisfaction. I consent to orthodontic treatment.

Signature: _________________________ Date: _____________

Witness: ___________________________ Date: _____________