The most natural way to replace a missing tooth.
Successful orthodontic treatment is a partnership between the doctor and the patient. The doctor and staff are dedicated to achieving the best possible result for each 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 the 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
The purpose of this document is to explain ClearCorrect clear aligners and also to inform you of potential risks associated with their use. ClearCorrect clear aligners are an orthodontic treatment in which the patient wears a series of clear, removable aligners that gradually move the teeth to improve 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
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 ClearCorrect 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 ClearCorrect clear aligners 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 ClearCorrect, 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 of my treatment. I understand ClearCorrect is not a provider of dental, medical or health care services and cannot and does not practice dentistry, medicine or give medical advice.
I understand before beginning, and in some cases during, treatment it will be necessary to take impressions, radiographs (x-rays) and photographs for diagnosis, professional review by my doctor or other consulting dentists and orthodontists, and case submission to ClearCorrect. 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 or ClearCorrect 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 either my doctor or ClearCorrect, shall be made only with my prior written authorization (for which I acknowledge my doctor or
ClearCorrect 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 terms of this Informed Consent and Agreement.
I had a long overdue deep cleaning, root canal/crown, AND fillings within a month. Dr. Thurman, Morgan, Kathy and staff were very attentive and kind with not ONLY the procedures and explanations but with checking up on me after the root canal. Also great at helping me figure out my insurance coverage and payments. Dental Elements is GREAT.- Steve
Your Decision to Choose Us as your Dental Health Partner is a Great Compliment.