Hebron Smiles - Consent Regarding Your Treatment Plan

IMPORTANT INFORMATION AND INFORMED CONSENT REGARDING YOUR TREATMENT PLAN
Patient’s Name*

First NameLast Name
Hebron Smiles, Adnan Saleem, DMD, Cameron Hamidi, DDS, MPH, Blanca Lemus, DDS, Anas Athar, Orthodontist, and team (the “Practice”) provides the following information to you related to your treatment.

YOUR TREATMENT PLAN

A comprehensive dental examination has been completed to determine the current condition of your teeth and gums. Based on this exam and discussions with you, the Practice has recommended and presented to you a custom-designed treatment plan (“Treatment Plan”). The purpose of this Treatment Plan is to improve the health, function, and/or appearance of your teeth and gums. Your Treatment Plan involves one or a combination of the following (perhaps along with other recommended dental procedures): veneers, crowns, bonding, fillings, inlays, onlays, tooth whitening, root canal therapy, gum or tooth contouring. Below are summary descriptions of some of these procedures. You may have also been shown photographs of the recommended procedures for you, heard the Practice’s explanations, and/or seen multimedia presentations illustrating the primary procedures proposed for your Treatment Plan.

DESCRIPTIONS OF CERTAIN DENTAL PROCEDURES

Porcelain Veneers are shells of porcelain that are bonded to the teeth. They typically require some roughening or reduction of the outer tooth structure. The Practice will endeavor to minimize the tooth reduction necessary under the circumstances to achieve the desired aesthetic and functional results. At a later visit, the veneers are bonded onto the prepared teeth. The veneers may be designed and fabricated in a variety of shapes and sizes to modify the appearance and function of teeth, including a V-shape that covers the front and backside of the teeth (for example, when opening a bite).

Crowns are life-like looking tooth restorations made out of porcelain or porcelain plus other materials. A crown covers the entire tooth structure. Typically, more tooth structure is removed to prepare for a crown placement than for a veneer. Crowns may be recommended for teeth requiring additional support due to a loss of healthy tooth structure.

Bonding/ Filling is a term that is commonly used to refer to the placement of composite resins on teeth. Bonding can be used to make a tooth-colored filling for small cavities and repair broken or chipped tooth surfaces. It can also be used to close spaces between teeth.

Inlays or Onlays may be the recommended treatment when individual back teeth are broken down but retain enough healthy tooth structure to allow for the restoration of certain voids in the tooth structure. The tooth is prepared much like a normal filling or a short crown. The restoration material is custom fabricated out of composite resins, porcelain, or porcelain and gold and bonded into the void.

A Bridge is a replacement made for missing teeth. It is composed primarily out of porcelain, which is bonded to adjacent teeth. These abutment teeth may require some reduction or crowning in order to support the teeth being replaced.

Whitening is performed by applying a peroxide gel to the teeth. This can either be done in our office in an accelerated method or in a take-home system. The peroxide reacts with the tooth structure to safely whiten the teeth. Porcelain or composite restorations will not whiten with peroxide.

Root Canal Therapy consists of the removal of the infected or irritated nerve tissue that lies within the root of the tooth. This is a possible risk when tooth structure is removed from a tooth or the tooth receives trauma. Usually, in the same visit, the canal where the nerve is located will be reshaped and prepared to accept a special root canal filling material. The root canal is then sealed with sterile, plastic material.

Tooth Contouring is the reshaping of the existing tooth structure by removing small amounts. We give particular attention to the edges of the upper and lower front six teeth, which may be reshaped to create a more aesthetic result.

Occlusal Guard (night guard) is a removable appliance worn to minimize the effects of clenching/grinding the teeth.

Gum Contouring is the reshaping of the gum tissue, which is many times done to give a more symmetrical appearance.
CUSTOM PREPARATION

Each person is unique and presents a different set of circumstances. Some of these circumstances are not revealed until during the procedure itself (for example, decay hidden under old crowns, etc.) or after. Therefore, the exact nature of the tooth and gum preparation for your Treatment The plan may vary somewhat from tooth to tooth and may vary from the general descriptions you have read above or seen elsewhere depending on the amount of decay (if any) present, the shape (e.g., gaps, chips, size) and position (e.g., the amount of rotation, spacing or flaring) of the teeth, and the desired look and function of the final restorations. As a result of these and other reasons, the exact nature and contours of the preparation of your teeth and the resulting restorations cannot be known until they are performed. During the course of treatment, unknown or unforeseen conditions may be revealed that necessitate a modification of the proposed Treatment Plan (e.g., a veneer preparation may become a crown prep). The dentist will exercise her professional judgment to perform a conservative preparation of your teeth and to make other necessary decisions regarding the means, manner, and method of any procedures as they deem appropriate to achieve the desired results of the Treatment Plan or as they otherwise deem advisable under the circumstances.
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SPECIFIC RESULTS NOT GUARANTEED

The dental procedures described above have a high degree of success. Human tissues, however, react differently to dental treatment depending on a variety of factors. Each individual case is different and the exact result for each specific case is difficult if not impossible to guarantee. Thus, as with any branch of medicine or dentistry, the proposed Treatment Plan contains no guarantee of specific results. There are many variables that determine how long restorations or whitening can be expected to last, including general health, maintenance of good oral hygiene, regular dental checkups, diet, etc. Therefore, no guarantees can be made or assumed regarding the longevity of restorations or whitening. If you have been provided computer-generated imaging of your smile, you understand that this is an artificial mechanism to serve as a basis for a discussion of treatment, and in no way, provides a warranty or representation of specific results. Natural teeth themselves are not “perfect” and contain certain embrasures, striations, and color variations. The dentist will use her artistic skills to specify the shades, coloring, shape, and sculpting of the restorations to make what in their experience are very realistic replicas of teeth. As with any type artistic endeavor, however, aesthetics is a highly subjective perception. You will be allowed to view and approve the lab fabricated porcelain restorations prior to bonding in. Once restorations are placed, and your approval is given, any redo’s based on the shade, coloring, shape, sculpting, and/or other aesthetic issues will be at the Practice doctor’s sole discretion and at current rates. Therefore, you may want to bring a friend or loved one to attend the seat appointment to help approve the restorations.
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ALTERNATIVE TREATMENTS

There are alternative treatments to the Practice recommended Treatment Plan, which may include, but are not necessarily limited to one or more various combinations of veneers, crowns, bonding, onlays, inlays, whitening, contouring of teeth or gums, bridges, dentures, extractions, root canal therapy, fillings, orthodontics, non-surgical therapy, tooth extractions, implant treatments, as well as other dental treatments. Please make sure you have had an opportunity to ask about these and had them explained to your satisfaction.
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NON-TREATMENT OPTION

One option is to have no treatment performed. This alternative may entail a number of actual or potential risks, which are difficult or impossible to quantify or predict for specific cases. Some of the risks of on-treatment may include, but are not necessarily limited to, worsening of any existing symptoms, deterioration of aesthetics or function of your teeth, changes to biting, tooth, head and/or neck pain, fracturing of teeth, discoloration or staining of your teeth, rotation or movement of teeth, TMJ complications, additional wear of your teeth to the point they are not candidates for reconstruction, loss of teeth, difficulty chewing, loosening of teeth, need for dentures, gum recession, bad breath, inability to perform adequate oral hygiene, abscesses or infection, pain, tooth sensitivity, tooth movements, worsening periodontal condition, deeper pockets, and other oral health problems.
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RISKS AND INCONVENIENCES

Inherent in Practice’s proposed Treatment Plan (as well as with many similar or other dental procedures) are certain actual and potential risks and inconveniences, which vary based on individual circumstances and variations in teeth and gums. These risks and inconveniences may last for a short or indefinable length of time. They include, but are not necessarily limited to swelling, pain, tooth sensitivity, bleeding, bruising, discoloration, gum recession, abscesses, the need to repeat all or part of the procedure for known or unknown reasons, gagging, exposure of crown margins or edges, numbness, gum, bone or teeth inflammation, lisping, speech impediments or speaking difficulties, infections, transmission of bacteria or virus, changes in facial appearance, stretching of the mouth resulting in cracked corners, stiffness of facial muscles, changes in occlusion, tooth mobility, loss of teeth, oral surgery, food impaction, root staining, oral opening restrictions, tissue sloughing, continued periodontal disease, implant rejections, root canal therapy, numbness of lip, chin, and gums, dental neuropathy, temporary or permanent numbness or tingling in the lip, tongue,teeth, gums, chin, cheek or jaw area, nerve problems, paresthesia, joint pain/disorder, need for a night guard,accidental nicks or cuts from dental instruments or needle sticks to the body, injuries to adjacent facial area and teeth, fillings in other teeth, other tissues, sutures, chipping, breaking or loosening of the temporary or permanent restorations, accidentally swallowing or aspirating restorations, materials or dental tools referred pain to the ear, neck, jaw or head, temporomandibular joint (jaw joint) problems, nausea, allergic reaction, bone fracture, delayed healing, sinus complications, adverse reaction to drugs, medications, and/or anesthetic(including nitrous oxide), respiratory distress, heart failure, or death. You understand that your condition may be the same, better or worse after treatment. If previously placed dental restorations are in place on teeth, the Treatment Plan may entail additional alteration of tooth structure to properly prepare these teeth for new restorations, and/or other unknown or unspecified problems or risks, which the Practice may or may not have encountered, and which are difficult or impossible to predict or quantify.
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MAINTENANCE OBLIGATIONS

For successful treatment results and to lessen the dangers of complication, you agree to comply with your individualized maintenance program and keep excellent oral hygiene. It is typical to need follow-up visits for occlusal or other adjustments. You agree to notify the Practice at the soonest possible moment in the event that you experience pain or discomfort that you believe may be related to Practice treatment. You agree to keep your follow-up appointments and to follow recommended treatments for your Treatment Plan as well as follow other precautions and recommendations that may be provided as part of your pre-op or post-operative instructions.
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YOUR CONSENT

I acknowledge that the Practice has explained to me in general terms the diagnosis of my condition, the basis for his or her Treatment Plan recommendations, general descriptions of the proposed Treatment Plan, the alternatives (including non-treatment) and the risks and inconveniences. I have been given the opportunity to ask any questions and any such questions have been answered or explained to my satisfaction. By signing below, I acknowledge that I am above 18 years of age, have been given time to read and have read the preceding information in this document and I agree to assume the risks and inconveniences of my treatment. I consent to the making of records, including x-rays, photographs, prescriptions, and other information, which may include personal information before, during, and after treatment (together, “Records”). My Dentist may disclose my Records for treatment, payment, or healthcare operations, including disclosure to laboratories, other dental offices or professionals involved in my care, and to my insurance providers.

I understand this form and I consent to the performance of the Treatment Plan as described herein.
Is the patient under 18 years of age or consenting to the care of another?*

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Orthodontic Consent Form
Phase I (Interceptive Treatment)/ Phase II (Full Braces)/ Invisalign

Hebron smiles (dentist) hereby agrees to provide the agreed upon orthodontic services, such as: consultation, diagnosis, insertion of braces (as necessary), treatment plan, subsequent adjustments, and providing of other appliances (as needed); I set of retainers is included. Retainer types are determined on a case basis.

Extended treatment Terms

- If treatment should extend 6 months past estimated treatment, additional monthly payments will be required. The patient understands the amount of time necessary to complete treatment cannot be determined with certainty. Many factors affect treatment estimation. Some of those factors include the patient’s facial growth pattern, muscle habits – tongue thrusting, finger sucking, and mouth breathing. Additionally, patient cooperation, compliance with instruction, keeping appointment, wearing elastic, appliances, broken appliances and broken brackets may length of treatment.

Additional Charges

- After 5 occurrences of broken brackets or bands - $25
- Records requested by an external dental office or by the patient for a personal copy, will be billed at $75.
- Other items such as permanent retainers, night guards, spaces maintainers, lost appliances.
- General dental treatment, including but not limited to: extraction, cleaning, and filling.

Treatment Time

- Treatment time is an estimate, not an exact science, In the event treatment is completed in less than the estimated time monthly payments will continue until the payment terms of the finance contract are fulfilled. Monthly payments do not correlate to treatment months, months, and are considered a separate agreement.

Discontinuing Treatment

- If the patient transfers out or discontinues treatment during the contracted orthodontic period, the financial contract will be pro-rated as follows:
1. Twenty five (25%) of the contracted fee after bonding has been performed'
2. Monthly payment equal to the amount in your fiancé contract for each month of treatment.
3. The remaining amount will be credited to the patient.
- If the patient elects to discontinue treatment and requests removal of braces, a de-band fee of $150 will apply.

Appointments

- Appointments should be kept regularly, as directed by the dentist.
- The patient is responsible for all appointments and visits required to complete treatment.
- Missed or broken appointments can add to the length of treatment.
- Some appointments must be made at specific times, for certain orthodontic procedures because of the length of time and nature of procedure. We will try to accommodate school, work, or other conflicting schedules as much as possible.

Insurance

- Insurance claims will be billed for your convenience.
- If for any reason insurance does not pay their estimated mount, the patient becomes responsible for the remaining balance.
- This include loss of benefits or coverage, delay in payments (60 days) , or pre-determinations.
- Insurance estimates are not a guarantee of payment.
- Benefit elections are not a guarantee of payment.
- Benefit elections are handled between you, your insurance company, and your employer
- If your benefit were based on discounted fees or a discount off our usual fee and coverage is lost, your account will be recalculated based on our current cash pricing, or new benefits will be considered.

Compliance

- The patient agrees to have their teeth cleaned and examined by a general dentist every 3-6 months during treatment.
- Regular appointments are necessary to advance treatment, if the patient fails to show for 3 consecutive appointments, we will assume the patient has elected to discontinue treatment, and will be dismissed from the practice. If the patient chooses to restart treatment, a $150 charge will apply plus any outstanding balance.

The dentist at any time may require an orthodontic re- consultation appointment. The patient will be required to be present at this visit if the patient is a minor. The dentist will evaluate the progress of treatment and make sure the teeth and gums healthy. If necessary your braces may be removed, and you will be referred to the general dentist or other dental specialist for treatment. This is ensure that your teeth and gums remain healthy whole you were braces.

If necessary the dentist may discontinue treatment, and dismiss the patient from the practice if in their professional judgment the case cannot be completed successfully due to patient non-compliance or failure to cooperate.
Orthodontic Informed Consent
Before beginning orthodontic treatment, you should be aware there are inherent risks and limitations. These are seldom enough to rule out treatment. but should be carefully considered before deciding to begin orthodontic treatment. Please note that it is impossible to list. Every possible circumstance and the following must be considered a patient list. Please read this consent carefully and ask for an explanation of any you do not understand. A certain amount should be expected when braces are put on and at each wire change.
Treatment Process - It is impossible to predict the amount of time each patient’s treatment will require. Lack of facial growth, gum disease, poor corporation, missed appointments, and broken appliances are most common contributing factors. *
(Your Initials)
Removal of Teeth - Sometimes teeth must be extracted as part of the orthodontic process. This will be based on the dentist’s judgment of the case. Such removal may include, but is not limited to, third molars (wisdom teeth) or bicuspids and will not be done by the dentist, but by a general dentist or oral surgeon as deemed necessary and is not included orthodontic treatment fee. If you refuse extractions and it subsequently becomes necessary (due to poor results) to extract teeth originally diagnosed for extraction, the entire case will be considered a ‘Re-start’ and will be charged as entirely new treatment at full. Do not have any extractions or have bridges placed without consulting your dentist. *
(Your Initials)
Late Growth Changes - If growth becomes disproportionate. The jaw relationship can be seriously affected and original treatment objectives may not be met.*
(Your Initials)
Additional Treatment - Unforeseen circumstance (growth changes, late extractions, gum disease, act.) may result in a form of treatment not previously discussed. If this occurs, the reasons for the change in treatment and any additional fees will be carefully explained before proceeding. *
(Your Initials)
Success of Treatment - We cannot guarantee the proposed treatment plan will be successful or to your complete satisfaction. Due to individual patient differences, there exists the possibility of failure, relapse or selective re-treatment, despite the best of case. Much of the success of treatment depends on the understanding and cooperation of the patient. Appointments must be kept as scheduled, appliances, and headgear must be worn as directed and good oral hygiene must be maintained. *
(Your Initials)
TMJ Pain - Patients may suffer from noise or pain near the ear in the joint (TMJ) of the lower jaw as the bite is changed. Depending upon the severity of my condition. I may be referred to a dentist who specializes in TMJ treatment. the cost of which is my responsibility. *
(Your Initials)
Injury from Appliances - Headgear instructions must be carefully followed. Brackets and wires can be dislodged or broken and can be swallowed or inhales. The risk is increased when the patient ignores advice and recommendations. Occasionally dental instruments may poke, scratch or cause a blow to the tooth with potential damage or soreness to oral structures. *
(Your Initials)
Devitalization - It is possible for a tooth to die during orthodontic treatment, especially if it was previously injured or traumatized. Such previous injures cannot be detected by the orthodontic. Root canal therapy may be recommended in such cases. Teeth which have been previously treated endodontically, may become symptomatic and any additional treatment is the patient’s responsibility.*
(Your Initials)
Miscellaneous Conditions - Decalcification, decay. Gum disease, mletion, etching, pain, swelling, tooth semiwet, mobility, gum and bone recession are some problems which may occur if the patient does not cooperate with brushing or flossing and have regular checkups with thee general dentist. Cleaning and cavity clearance are required every six months during orthodontic treatment. Proper dietary control is essential. If periodontal disease occurs during the course of treatment. If may be difficult or impossible to control the loss bone and subsequent loss of teeth. Orthodontic may aggravate a preexisting periodontal condition. When the case is complete and the patient is ready for dabanding. It is impossible to determine if filling tooth structure may be damaged during routine dabaning. The patient is responsible for any restorations after or due orthodontic treatment or debanding.*
(Your Initials)
Ceramic /Metal brackets - Some patients experience bracket breakage and or damage to teeth. If brackets fracture outside of the office, it may result in sharp edges. Which might be harmful to the patient. Also, these brackets may cause enamel flaking and or enamel fracturing on brand removal.*
(Your Initials)
Root Resorption - Shortening of root ends can occur when teeth are moved during orthodontic treatment especially in open bile/under cases. Under healthy conditions, the shortened roots are usually not a problem. Trauma, endocrine disorders or idiopathic (unknown) reasons also cause this problem. Severe resorption can increase the possibility of premature tooth loss. *
(Your Initials)
Orthodontic Surgery Cases (orthognathic) - Many complex factors influence the course of treatment and it is possible in certain cases that law modification surgery may be required at any phase during treatment. It is understood you have the choice to discontinue (deband) or be referred to another dentist to treat the surgical phase of the case. *
(Your Initials)
Relapse - Any dentist corrections will be made following the highest standards: however, unless the patient carefully follows retention instructions, relapse may occur. Lost or broken retainers should be replaced immediately.*
(Your Initials)
Periodontal Disease - Understands that inflammation of the gum and loss of bone, known as periodontal disease, can develop during orthodontic treatment due to many factors but most commonly due to inadequate oral hygiene and the difficulty of cleaning around orthodontic appliance. Therefore, periodic examinations and necessary cleanings are required a minimum of every six months at my general dentist. Depending upon the severity of my condition. I may be referred to a periodontal specialist for evaluation and treatment and as a result. Orthodontic treatment may have to be suspended or terminated. Cleanings and periodontal treatment are not included in my initial fee for orthodontics and the cost of which is my responsibly. *
(Your Initials)
Impacted Cuspids - In attempting to move impacted teeth (teeth unable to come in normally), especially cupids (eye teeth) various problems are sometimes uncounted which may lead to periodontal problems, loss of tooth vitality (dead teeth), andiron complete loss of the tooth. *
(Your Initials)
I have read and understand the above. I also understand orthodontics is not an exact science; therefore, results cannot be guaranteed. While every effort will be made to complete the treatment with the same dentist this cannot be guaranteed.
I understand that each dentist is an individual practitioner and is individually responsible for the orthodontic care rendered to me. I understand that no other dentist other than the treating dentist non-other affiliated company is responsible for my dental treatment.
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IMPORTANT INFORMATION AND INFORMED CONSENT REGARDING YOUR TREATMENT PLAN

Orthodontic Consent Form

Orthodontic Informed Consent