INFORMED PATIENT CONSENT

CLEAR ORTHODONTIC RETAINER (ESSIX APPLIANCE)

The information provided below is in respect to the provision of a removable orthodontic retention appliance.

I consent to Cosmetic & Laser Dentistry Centre producing an orthodontic retention appliance (“retainer”) to use as instructed. I understand there are several retention methods which have been explained to me by the dentist.

I understand the purpose of the removable orthodontic retainer is to maintain the position of my teeth and also protect the existing restorations (composite bonding).

I acknowledge it is my responsibility to ensure the retainer is worn for a minimum of 18 hours each day for at least 12 months and must maintain good oral health as instructed, including regular brushing, flossing and regular professional check-ups.

I understand that failure to use the retainer as instructed may result in orthodontic relapse, meaning my teeth may move out of their current alignment; and that failure to wear the retainer as instructed may result in damage to my existing restorations.

I acknowledge that costs are payable to replace or repair my existing restorations if they are damaged in the future; or to replace the orthodontic retainer if it is lost or damaged.

Acknowledgement of treatment presented and explanation of appropriate fees for service, terms and conditions:

By signing this form, I confirm I have read and understood the above informed consent document, which has legal significance. All of my questions concerning orthodontic retention have been answered by the dentist. I understand the human biological system is complex and is not completely predictable. Although every care is taken, I acknowledge that the treatment outcomes may vary from that prescribed at the time of treatment.