Patient Agreement and Informed Consent for

Cosmetically Focused Tooth Alignment

This Patient Agreement contains important information about your treatment. BY SIGNING THIS PATIENT AGREEMENT,
YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED
HEREIN. Please read carefully and ask questions about any areas that are unclear:

Scope of Treatment:
reasonable time frame-usually 4-9 months. You may have aspects of your bite that will not addressed with this

problems, displaced tooth roots and midline discrepancies. Full correction of the items mentioned here can
oftentimes involve years of orthodontic treatment. The goal of this cosmetically focused and short-term
orthodontic treatment is to correct your chief cosmetic complaints, which you have shared with us. This treatment
is not a replacement for traditional comprehensive orthodontic treatment. This cosmetically focused treatment
is an alternative for people who are not interested in traditional comprehensive orthodontic treatment and are
seeking a more cosmetically focused orthodontic treatment option that can be provided over a shorter period
of time.

Hygiene: BRUSH YOUR TEETH, GUMS, braces and wires thoroughly after each meal and before going to bed.
Poor oral hygiene can result in puffy, bleeding gums and permanent white spots on teeth. INFLAMMATION AND
BLEEDING GUMS WILL DELAY YOUR TREATMENT. An interproximal brush is the best way to clean around your braces
and can be purchased in any grocery store/drug store. Use this brush between your teeth at the gumline. We do
reserve the right to suspend or delay treatment if your oral hygiene is poor. Keep your teeth and braces clean!

Hard Food: DO NOT EAT hard food such as popcorn, ice, caramels or hard candy. These foods can break the
brackets. CUT UP foods such as meats, apples, carrots etc. before eating them. (If abuse is noted on multiple
periodic treatment visits, a fee of $200 can be assessed.)

Soreness: After the braces are put on the teeth may be sore, usually for 2-4 weeks. Aspirin, Advil or Aleve may
be taken to relieve this. If the soreness prohibits eating even soft food, please phone for an appointment so any
necessary adjustments may be made. If the inside of the lips are sore, the wax that is provided can be used as
a cushion over the braces until the lips become accustomed. Taking pain medication prior to your adjustment
appointments can help minimize discomfort.

Jaw Joint: There are some patients who will develop a popping/clicking or other problems in their jaw joint during
or after orthodontic treatment. This is very rare. Usually, orthodontic treatment provides a positive effect on the
jaw joint. You should understand that pre-existing joint conditions can manifest as a popping or clicking after
orthodontic treatment but orthodontic treatment by itself has not been shown to cause popping/clicking of the
jaw joints.
Main Objective: I understand that the main objective of my orthodontic treatment is to align my teeth for
cosmetic reasons. My bite and the relationship of my back teeth are not the focus of this treatment. 3-6 months

term treatment. I fully understand that my course of treatment may not result in complete orthodontic correction.
This is not mainstream orthodontic treatment philosophy and many orthodontists will disagree with this type of
orthodontic treatment that does not aim to completely correct/change the bite relationship.

A Cephalometric X-ray will not be taken: A cephalometric x-ray is usually taken in association with traditional
comprehensive orthodontics. This type of x-ray shows the relationship of the skull, skeleton and teeth. This type
of x-ray does not provide us with essential information for performing cosmetic tooth alignment. Therefore, a
cephalometric x-ray is not typically taken in association with cosmetic tooth alignment. By signing this consent
form, you are communicating that you understand that this type of x-ray will not be part of your pre-treatment
records. If you desire more information about this topic, please ask the doctor.

Technique: Space will be made by enamel reproximation (minor tooth reduction). This allows limited tooth
movement in the area of the crowding. Rarely sensitivity is possible from this, but is transient and not common.
Alternative treatment options to enamel reproximation for making space include tooth extraction, which we only
perform in extreme cases of crowding, and expanding the dental arch is proven to be unstable in adult patients.
Upper and lower dental midlines will not be made to coincide for most cases as midline changes often require
years of treatment. Misshaped and abnormally long teeth will be reshaped as part of treatment. On occasion,
bonding may be needed to provide an even appearance of the edges of front teeth whether because of
stubborn tooth movement or misshaped teeth. Charges for bonding will be determined on a case-by-case basis.

Standard of Straightness: We seek to straighten teeth to a very high level with cosmetically focused orthodontic
treatment. If, however, numerous custom requests arise which the doctor feels will take an inordinate amount
of extra time or in fact may not even be possible to achieve, we reserve the right to refer you to an orthodontic
specialist for conventional comprehensive, 2 year, bite-changing orthodontic treatment, without a refund of
monies paid up until that point in treatment.

Retention: Teeth have a tendency to rebound to their original positions after orthodontic treatment. Very severe
problems have a higher tendency to relapse, and the most common type of relapse occurs with twisted teeth.
Retainers will be placed immediately to minimize relapse. . Full cooperation in wearing these appliances (full time

retainers.

Disputes: Should any dispute arise regarding fees, treatment, its outcome, or other matters associated with
treatment, I agree to seek resolution through arbitration (peer review process) in lieu of court in order to seek a
speedy and fair resolution of such issues. By signing this consent form I am agreeing to handle any dispute that
might arise as a result of treatment through a dental peer review process (arbitration).

Cleanings: You should have at least one professional cleaning during your treatment. If you have an appointment
for a cleaning scheduled, keep it! This is not required but highly encouraged.

Appointments: Please keep your adjustment appointments! Missed appointments can result in delayed completion.
Please notify us at least 48 hours in advance should you need to reschedule since another patient may need this
time slot. There can be a fee assessed for all broken appointments or short notice cancels. ($100) There are some
visits that are required after your braces are off (retainer checks etc.). These visits are very important. Relapse, bite
settling, and retainer or splint adjustments (or breakage) are just some of the items we wish to monitor in this stage.
Moving: If you plan on moving to another state during orthodontic treatment, it is usually advisable to complete

Disclaimer and Release of Liability: I understand that the dentist who is providing my cosmetic tooth alignment

Month Smiles, Inc. Six Month Smiles provider status denotes only that a dental professional has completed the
training course offered by Six Month Smiles, Inc. that is necessary to enable him or her to begin treating patients

attests only to my dentist’s attendance at, and completion of, the Six Month Smiles training course and does
not attest to, certify, or guarantee any level of skill or expertise or any quality of performance. I understand
and acknowledge that Six Month Smiles, Inc. makes no warranties or representations regarding, and does
not guarantee or certify the quality of, the services provided by my dentist or any other licensed health care
professional.

I HAVE READ THIS PATIENT AGREEMENT AND FULLY UNDERSTAND ITS TERMS.

Signature: ________________________________________________ Date: _________________