CONSENT FOR ORTHODONTIC TREATMENT

Date ­____ / ____ / _________

Patient Name ______________________________________

Chart Number _____________________________________

I request and authorise Dr. Mark Lynch and/or associates or assistants of his choice to perform the following treatment(s)/procedure(s) for: Patient Name:

Description of Treatment(s)/Procedure(s): _____________________________________ _______________________________________________________________________ _______________________________________________________________________

Description of Patient’s Condition/Problem(s) Being Treated: _____________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________

I further request and authorise the taking of oral-dental x-rays, impressions for dental casts, photographs, and the use of such anaesthetics as may be considered necessary or advisable by Dr. Mark Lynch to diagnose and/or treat my/the patient’s dental problem(s).

I have had explained to me, and I have had sufficient opportunity to discuss, my/the patient’s dental condition, the treatment procedure(s), and the benefits to be reasonably expected from this treatment, compared to alternative approaches and/or no treatment.

I understand that, generally, successful orthodontic care can be carried out with informed and co-operative patients. I am aware that orthodontic treatment, like treatment to any part of the body, has some risks and limitations. These are seldom severe or frequent enough to offset the advantages of treatment, but they should be considered in making the decision to undergo orthodontics. Specifically:

a) The mouth is sensitive to changes and the introduction of any appliance means that a period of adjustment is necessary. There may be some discomfort associated with orthodontic treatment. This usually can be resolved by using an over-the-counter non-aspirin pain medication.

b) Tooth decay, gum disease, and decalcification (permanent markings on the teeth) may occur if patients do not brush their teeth regularly and properly. Excellent oral hygiene is a must. Sugars and between-meal snacks should be eliminated, as well as hard and sticky foods because they can loosen, break and bend appliances.

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CONSENT FOR ORTHODONTIC TREATMENT continued

c) Teeth have a tendency to return to their original position after orthodontic treatment. Throughout life, tooth position is constantly changing. This is true for all individuals, regardless of whether they had orthodontic therapy or not. A common site for these changes is the lower front teeth, and some shifting movement in this area should be expected after treatment ends. To compensate for this, the orthodontist may move the teeth slightly beyond their desired final position. Faithful wearing of retainers will help reduce post treatment changes.

d) Impacted and unerupted teeth can cause problems during treatment, including loss of the teeth, gum problems, shortening of the roots, and ankylosis (fusion to the bone). The length of time to move impacted and unerupted teeth can vary considerably.

e) Occasionally, growth of the jaws becomes disproportionate, changing the relationship of the upper jaw to the lowerjaw. In some cases, surgery or additional orthodontic treatment may be needed to correct this disproportionate growth.

f) It is essential that the patient maintain regular dental examinations during the orthodontic treatment period.

g) There are occasions when it is difficult to accurately predict the length of treatment time, so the orthodontist gives a best estimate. In some cases, treatment time may take longer because of more or less growth than expected. Sometimes, it may be caused by poor co-operation by the patient. Broken appliances and missed treatment appointments may also be important factors in slowing down treatment progress and may affect the quality of the final result.

For purpose of advancing medical-dental education, I give permission for Dr. Mark Lynch to make and use any records including x-rays, dental casts, x-ray tracings, and photographs of me/the patient for diagnostic, scientific, educational, or research purposes.

I understand that orthodontics is not an exact science and acknowledge that no guarantees have been made to me regarding the results of the orthodontic treatment.

Consent Certification

I certify that I have explained the nature, purpose, benefits, the usual and most frequent risks and hazards of, and alternatives to, the treatment and procedures specified above.

I have offered to answer any questions and have finally answered such questions. I

believe the patient/relative/guardian understands what I have explained and has

consented to the proposed treatment and procedures.

Signature of Dentist:

Date: _________ ______ Time: ___________

Print Name: