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LETTER OF INFORMATION AND CONSENT AGREEMENT

Orthodontic treatment results can vary per patient like any treatment of the body, much of its success depends on the understanding and cooperation of patients. While recognizing the benefits of a pleasing smile and healthy functional teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has some hazards, inconveniences, and limitations. These drawbacks seldom outweigh the long-range benefits, but should be considered in making the decision to wear orthodontic appliances.

The following information is routinely supplied to anyone considering orthodontic treatment in our office. Please read through this form carefully and ask the doctor or Treatment Coordinator to explain anything you do not understand. Clarify what is expected of you as a patient, or as a parent of a young patient, to achieve excellent results.

Perfection is always our goal. The Orthodontist will use his / her knowledge, training, skill and experience (three extra years of orthodontic specialty training are required by the American Dental Association before one can be called an orthodontist) to achieve perfect function that is also aesthetically pleasing. Much depends on the patient's growth patterns, genetics, oral health, and cooperation.

Throughout life, tooth positions are constantly changing. This is true with all individuals regardless of whether they have worn braces or not. After orthodontic treatment, patients are subject to the same subtle changes that occur in non-orthodontic patients. In the late teens and early twenties, orthodontic patients may notice slight irregularities developing in their front teeth. This is particular true if their teeth were extremely crowded prior to treatment. Prolonged wearing of retainers may be the only way to prevent this if it becomes undesirable.

Orthodontic appliances do not cause cavities. They may trap particles and increase the likelihood of a patient developing cavities or decalcification marks. Decalcification (permanent marking on the teeth), tooth decay, or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Patients are able to prevent these problems with a combination of a proper diet, good tooth brushing habits, and regular checkups with the dentist. Sugar and between-meal snacks should be eliminated. Occasionally, periodontal (gum) problems present before orthodontic treatment may be worsened by wearing braces and may require treatment by another specialist.

Cold sores, canker sores, and irritations or injury to the mouth are possible while wearing braces. Loose or broken wires and bands can also scratch or irritate your cheeks, gums, or lips. Your orthodontist will give you soft wax to cover problem areas like this. Also allergic reactions to dental materials or medications are rare, but do occur occasionally.

Teeth must sometimes be extracted as part of the orthodontic procedure. Your orthodontist will recommend removal only if it improves your prospects for successful treatment. There may be a need for fillings, crowns, bridges, gum treatment or other dental procedures before, during orthodontic treatment. On rare occasions the nerve of a tooth may become abscessed. A tooth that has been irritated by a deep filling or even a minor blow may require treatment by another dentist. In some instances, the root ends are shortened during treatment. This process is called root resorption. Under healthy circumstances, the shortened roots are no disadvantage. There are rare circumstances that may lead to loss of teeth due to root resorption. There is no way to foresee whether this will happen, and nothing can be done to prevent this from occurring.

There is also a very small chance that pain may occur in the lower jaw joints, i.e. temporomandibular. Tooth alignment or bite correction can usually improve tooth-related causes of jaw discomfort, but additional treatment by another dentist may be required.

Occasionally, a person who has growth normally and in average proportion may not continue to do so. If growth becomes disproportioned, the jaw position can be affected and original treatment objectives may have to be compromised. Skeletal growth disharmony is a biological process beyond the Orthodontist's control. This disharmony may necessitate surgical correction in conjunction with orthodontics treatment.

Orthodontic treatment can only be successful if all parties are willing, and able to cooperate by wearing headgear, elastics, and retainers as instructed. Otherwise the length of treatment may be extended or the results may be compromised. We appreciate your confidence in selecting our office. We want you to be fully informed, so ask questions anytime. During the period of orthodontic treatment, we may make models, x-rays, and photographs which may be used for professional reference and display, orthodontic journals, books, meetings, and patient educations.

I have read and understand the letter of information and with this knowledge, consent to treatment for Charlotte Bright.*

Your Orthodontic Appointments

In order to ensure quality orthodontic care, it is important that both parents and patients understand the manner in which we schedule your appointments. Our team values both you and your time so we make every effort possible to stay on or ahead of schedule.

We are happy to work around your child’s important classes and provide your child with school excuses for scheduled orthodontic appointments. It is important for your child to turn these into the appropriate school officials.

Interrupting your work schedule and your child’s studies as infrequently as possible is very important to us. Since most of our patients are of school age, it is unavoidable that some school time appointments will be necessary. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our long appointment patients during school hours, it leaves room in our schedule to see more patients during after school hours.
Long Appointments: Banding, Bonding and removal of braces. These are more detailed and technique sensitive appointments. Therefore, these appointments will be scheduled during our quieter morning hours.
Repairs: Loose bands or brackets, broken arch wires or ties, broken appliances or retainers. These appointments are always scheduled during school hours since they are long visits. If a needed repair is discovered during a regular appointment, please note that we will make every effort possible to make the repair, but an additional appointment may be required in order to not inconvenience scheduled patients.
Emergencies: Pain, swelling or bleeding. This usually results from trauma to the face or mouth. These patients will be seen as soon as possible and either appropriate care given or a recommendation to another specialists will be provided for treatment.
Appointments missed or not cancelled within 48 hours: Another appointment will be scheduled but may require waiting four to six weeks which could extend the length of your treatment. An appointment made during school hours may be arranged sooner.
Broken bracket Policy: To be defined as anything glued to the teeth. As a courtesy to our patients, we will replace 5 broken brackets free of charge.  Broken brackets should not be an issue if instructions regarding foods to avoid are carefully followed. These appointments are repairs and must be made during school hours.
We appreciate your understanding and please sign that you have read, understand and agree to the scheduling information above:
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Informed Consent

I acknowledge that I have read and understand the Informed Consent information outlining general treatment considerations and potential problems and hazards of orthodontic treatment and that actual results may be different from the anticipated results. I also understand that there may be potential hazards and problems not described in the information. I am able to read, write and comprehend English. I have had the opportunity to discuss treatment considerations, alternative treatments and risks, and have been asked to make a choice about my orthodontic treatment.*
I have asked all questions to clarify any areas I did not understand and I am satisfied with the response(s) received. I further understand that, like the other healing arts, the practice of orthodontics is not an exact science and, therefore, results cannot be guaranteed. I authorize the orthodontist and staff of his/her practice to provide orthodontic treatment to me.*

Auto Pay Plan Information

Payments must be made between 1-30 of the month and are late by 1st of the next month.

Administrative Fee Agreement

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 25.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 26.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 27.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 28.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 29.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 30.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 31.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 32.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 33.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 34.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 35.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

A ONE TIME NON-REFUNDABLE ADMINISTRATIVE FEE OF $ 36.00 WILL BE CHARGED TO MY PAYMENT SOURCE SPECIFIED ABOVE. I ACKNOWLEDGE AND AGREE THAT I AM RESPONSIBLE FOR PAYING THIS FEE.

I acknowledge the debit to my account will reflect OrthoSynetics, Inc., and/or this office’s Doctor/Practice name as the creditor. I authorize OrthoSynetics and/or the Doctor/Practice to automatically charge my account in the amount listed above and acknowledge this agreement will remain in effect until cancelled by myself, OrthoSynetics, the Doctor/Practice, or my financial institution. I can cancel my agreement at any time by calling or writing to OrthoSynetics, 3850 North Causeway Blvd., Ste. 800, Metairie, LA 70002, (866) 255-1016, or by informing this doctor’s office.

A service charge will be applied to any returned EFT pre-authorized payment or additional payments.

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Account Information

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PHOTO RELEASE FORM

  • I hereby consent to the taking of a photograph(s) of the undersigned which may be reproduced and/or used in any and all advertisement or promotional purposes for Dr. Davidson individually and/or as a part of Davidson Orthodontics, including but not limited to television, print ads, websites, Facebook, Twitter and all other social media.
  • I also authorize the use of the photograph(s) by Dr. Davidson in connection with educational purposes conducted by him/her. This release includes my waiver of my privacy rights pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and any rules and regulations promulgated by authorized agencies and persons thereunder.
  • In addition to the foregoing, in giving this consent, I also release the advertising department of OrthoSynetics, Inc. and Dr. Davidson from liability for any violation of any personal or proprietary right I may have in connection with such photograph reproduction or use.
  • This release and consent shall be valid unless and until I revoke it in writing and deliver the revocation to Dr. Davidson and/or Davidson Orthodontics.
I am a patient of Dr. Davidson and/or Davidson Orthodontics and more than 18 years of age.*
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