Successful orthodontic treatment is a partnership between the doctor and the patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should consider the option of no treatment at all by accepting their present oral condition. You should also ensure that you have discussed all orthodontic alternatives available to you with your doctor prior to beginning treatment.
Please read this information carefully, and ask the doctor to explain anything you do not fully understand. Ensure you know what is expected of you as the patient (or as the parent/guardian of a young patient) during treatment.
Clear aligner therapy is an orthodontic treatment in which the patient wears a series of clear, removable aligners that gradually move the teeth to improve the bite function and/or esthetic appearance. This treatment is intended to provide the end benefits of traditional “wired” orthodontic treatment, such as straight teeth and improved bite function, as well as the following benefits that are only available when going wireless:
Although the benefits generally outweigh the potential risks, all factors should be considered before making the decision to wear aligners. If you choose to undergo clear aligner therapy, ElleJordan Studios, a New Jersey based dental laboratory, will manufacture aligners customized to your teeth based on your doctor’s prescription. Your doctor (not ElleJordan) is responsible for delivering and managing your care.
As with other orthodontic treatments, clear aligners may carry some of the potential risks described below:
I have read and understand the content of this document describing considerations and risks of clear aligners. I have been sufficiently informed and have been given the opportunity to discuss this form and its contents with the undersigned doctor, and to have my questions adequately answered. I have been asked to make a choice about my treatment, and I hereby consent to receive treatment with clear aligners manufactured by ElleJordan as planned, prescribed and provided by the undersigned doctor. I agree to follow my doctor’s treatment exactly as s/he plans, prescribes and provides it for me, and I understand that any questions, concerns, or complaints I have regarding my treatment must be communicated to my doctor as soon as they arise.
I acknowledge that neither my doctor nor ElleJordan, its employees, representatives, successors, assigns, or agents, have, can, or will make any promises or guarantees as to the success of my treatment or give any assurances of any kind concerning any particular result manufacturers medical devices based on instructions from the prescribing doctor. I understand that I should always contact my doctor (not ElleJordan) regarding my expectations, difficulties, results, or any other aspects of my treatment.
I understand that it may be necessary to take impressions, intraoral scans, digital model scans, radiographs (x-rays), and/or photographs for diagnosis, professional review by my doctor or other consulting dentists or orthodontists. I recognize that these will be included in my medical records, which records encompass “individually identifiable health information” as that term is defined and protected by the HIPAA Privacy Rule. I understand that my doctor, as a covered entity under HIPAA, is not required to obtain my consent to use and disclose my individually identifiable health information for treatment, payment, and health care operations activities, but has chosen to do so voluntarily through this document. I further agree that my doctor may use my medical records for research and educational purposes, but only to the extent that no individual identifiers, including but not limited to my name or address, are disclosed. I hereby consent to such uses and disclosure(s) as described herein.
Unless otherwise permitted or required by law, other uses and disclosures of my medical records, including advertising or marketing by my doctor or ElleJordan, shall be made only with my prior written authorization (for which I acknowledge my doctor or ElleJordan may use my contact information to seek to obtain). I acknowledge I will not, nor shall anyone on my behalf, seek or obtain damages or remedies – legal, equitable, monetary, or otherwise – arising from any use of my medical records that complies with the terms of this Informed Consent and Agreement.
I acknowledge I have read, understand, and voluntarily consent to the use of clear aligners in accordance with terms of this Informed Consent and Agreement.