Hebron Smiles - Silver Diamine Fluoride Treatment Consent Form

Silver Diamine Fluoride Treatment Consent Form
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Parent / Legal Guardian:
The permission of a parent or legal guardian is necessary for the dental treatment of a minor before any treatment can be started or completed by our office. While signing this form gives consent for us to treat your child, we encourage you to speak to any of our staff members, especially Dr. Coffman, if you have any questions regarding your child’s specific needs or treatment being provided. Silver Diamine Fluoride is a medication that is applied to an active area of decay (cavity) to kill the bacteria causing the cavity, prevent the formation of a plaque layer on the treated surface, and strengthen the tooth. It is very important that you are made aware that treating cavities with this medicine will cause color changes to the lesions (cavity). The areas of the tooth with active dental decay will turn dark black as the medicine is working. The healthy areas of the tooth will not be affected and will remain your child’s natural tooth color. The black color indicates that the treatment is successful.

It is also important that you are aware that this medicine will treat the bacteria causing tooth destruction, but will not restore the tooth structure that has already been affected by the disease process. Your child will still require restoration of the teeth (fillings, crowns, and possibly nerve treatment) if there is any loss of tooth structure. Dr. Adnan Saleem and our team will discuss the recommended timing of this treatment and will discuss the best way to provide this treatment to ensure that your child receives treatment in the least invasive, most predictable and least traumatic way possible. You will sign a separate treatment plan for the actual restoration (filling, crown, and/or nerve treatment) of your child’s teeth.

As a parent or legal guardian of the above patient, I grant Dr. Adnan Saleem permission to provide my child’s dental treatment as discussed. I also understand that this treatment may not be covered by my insurance (if applicable) and any estimates of insurance coverage discussed by any staff member at DCPD was provided to me as a courtesy. It is my responsibility to contact my child’s dental insurance company (including any insurance provided to my child by the state) to discuss and understand my child’s policy.

I agree to inform Dr. Adnan Saleem and the staff of DCPD of any changes in the patient’s medical history. This authorization is valid until revoked by me in writing.
Parent/ Legal Guardian Signature*

Clear
Relationship to Child
Date*

MonthDayYear
Date
Sample pictures of teeth treated by Silver Diamine Fluoride

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.
Parent/ Legal Guardian Signature*

Clear
Relationship to Child
Date*

MonthDayYear
Date
Should be Empty:

Silver Diamine Fluoride Treatment Consent Form

Orthodontic Consent Form

Orthodontic Informed Consent