Orthodontic Treatment Informed Consent Form

Patient Information

Name: _________________________ Date of Birth: _________________ Date: _________________________

Nature of Orthodontic Treatment

I hereby authorize Dr. _________________ and staff to perform orthodontic treatment as presented in my treatment plan. I understand that this may include but is not limited to:

• Installation of orthodontic appliances (braces, aligners, etc.)
• Placement of temporary anchorage devices if needed
• Use of other orthodontic appliances (elastics, headgear, etc.)
• Periodic adjustments and monitoring

Understanding of Treatment

I acknowledge the following aspects of treatment:

1. Duration: Treatment typically takes ____ to ____ months but may vary
2. Cooperation Required: Success depends on:
   • Keeping scheduled appointments
   • Maintaining excellent oral hygiene
   • Following appliance wear instructions
   • Adhering to dietary restrictions

Potential Risks and Complications

I understand that orthodontic treatment may involve:

• Tooth discomfort and sensitivity
• Risk of root resorption
• Potential for decalcification if oral hygiene is poor
• TMJ complications in some cases
• Possibility of relapse post-treatment

Financial Agreement

I understand:

• The total cost of treatment: $________
• Payment schedule: _________________
• Insurance coverage details: _________

Consent

I certify that I have read and fully understand the above consent form.

Patient/Guardian Signature: _______________ Date: _______________

Doctor Signature: _______________ Date: _______________