We would like to take this opportunity to welcome you into our orthodontic practice. The goals of our office for each patient are: Quality Service and Personal Attention.
In order to achieve these goals we would like to present to you our office procedures and policies. Please read the following information carefully. If you have any questions, please feel free to discuss them with Dr. Langford or any member of our team
FEES AND PAYMENTS:
The fee for orthodontic treatment is based on the specific diagnosis and treatment plan for the individual. The monthly payment agreement is not related to the number of times we see a patient in a given month. The time interval between appointments is usually 4 to 12 weeks. Even though we may not see a patient in a particular month, payment is still expected for that month. Your monthly payment will be due on the assigned day of each month and will be considered past due if not received by the end of the month. In the event the account becomes seriously delinquent and has to be collected, the undersigned agrees to pay all collection, court and attorney fees. There will be a $20.00 charge on all returned checks. We reserve the right to charge late fees and/or interest for payments that are behind schedule. Continued non-payment will result in cessation of treatment.
As a courtesy to our patients, we will file all insurance claims and accept assignment of dental benefits. However, please keep in mind that even though you may have insurance coverage, you are ultimately responsible for the entire fee. The knowledge of insurance benefits is ultimately your responsibility. Any failure of insurance to pay for ANY reason, including but not limited to coverage change, means you are then responsible for any unpaid balance.
Due to our commitment to staying on schedule, please contact our office if there are things loose or broken. This will allow us to allocate adequate time for the necessary repairs to be performed. If you fail to let us know that things are broken, we may not have the time necessary to fix the problem, and it will be necessary to reschedule.
Loose, damaged and broken appliances extend the treatment time considerably. Please take care of the appliances. When a patient has repeated appliance breakage or damage, a $25.00 fee will be assessed. Continued breakage could lead to the appliances being removed before treatment is completed.
This is the single most important factor in a successful orthodontic treatment! Patients who do not brush their teeth adequately and/or don’t follow instructions properly will have a very unpleasant experience with orthodontics and will not get a good treatment result. We will do everything possible to encourage the patient’s cooperation. If there is a demonstrated lack of cooperation exists, including poor oral hygiene, poor elastic wear or missing scheduled appointments, a compromised treatment result will be unavoidable. We are committed to keeping the teeth healthy throughout treatment. The braces will be removed if lack of brushing or missed appointments become a serious problem.
Everyone has busy schedules and has a preferred appointment time. We do understand. However, it is impossible to see all patients at their preferred time each and every appointment. We have set up a scheduling policy to try to meet the needs of the majority of our patients:
Our schedule is designed to allow us to see as many patients as we can each day to ensure we are able to help each of our patients progress quickly through treatment. Some appointment times may not fit perfectly in your schedule. We will work with you the best we can to meet your needs within the confines of our schedule. This means our longer appointments are scheduled earlier in the day. We thank you for your understanding.
Our goal is to see you at the time that you are scheduled and to have you on your way in a timely manner. To help us in accomplishing this, we ask that you call our office if you are running late. This will help us to prepare accordingly, or to reschedule if necessary. Without notice, we cannot guarantee that we will be able to work you in. Also, if you find that your appointment time will not work for you, we ask that you call our office at least 24 hours in advance and reschedule or cancel your appointment. Frequent missed appointments will increase treatment time and will result in additional fees being assessed.
**It is very important that you read and understand all of the above information. If you have any questions, please feel free to discuss them with us. We assure you that we will do everything we can to make orthodontic treatment a pleasant and worthwhile experience.
We have read and understand the office policy as outlined above and agree to adhere to these policies.
As a general rule, positive orthodontic results can be achieved by informed and cooperative patients. You should be aware, however, that orthodontic treatment has limitations and potential risks. These should be considered in making the decision whether to undergo orthodontic treatment. Orthodontic treatment usually proceeds as planned; however, as in all areas of the healing arts, results CANNOT be guaranteed, nor can all consequences be anticipated. The unknown factor in any orthodontic correction is the response of the patient to the orthodontic treatment.
All forms of medical and dental treatment, including orthodontics, have risks and limitations. Some of the primary concerns involving orthodontic treatment include:
1) Tooth decay, gum disease, or permanent white markings (decalcification) on the teeth WILL occur if the orthodontic patient eats foods containing excessive sugar and/or does not brush his/her teeth frequently and properly (removing ALL plaque). These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances.
2) In some patients, the roots of some teeth may be shortened during orthodontic treatment. Usually this shortening is minimal and does not have significant consequences, but on rare occasions it may become a threat to the longevity, stability and/or mobility of the teeth involved.
3) The bone and gum tissue which support the teeth may be affected by orthodontic treatment if an unhealthy condition already exists, and in some rare cases where it doesn’t. Inflammation of the gum tissue and loss of supporting bone can occur particularly if bacterial plaque is not removed daily through good oral hygiene.
4) Teeth have a tendency to change their positions after treatment. Proper wearing of the retainers should reduce this tendency. Throughout life the bite can change adversely from various causes, such as eruption of wisdom teeth, genetic influences which control the size of the tongue, the teeth and the jaws, growth and/or maturational changes, mouth breathing, playing of musical instruments and other oral habits – all of which are beyond the control of the orthodontist. There are times when tooth and/or jaw position may change adversely following treatment to a degree that additional treatment is recommended. The extent of further treatment would depend on, among other things, the nature of the problem and might involve the replacement of braces.
5) Occasionally problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing pain, headaches, or ear problems. These problems may occur with or without orthodontic treatment. Any of the above noted symptoms should be promptly reported to the orthodontist.
6) A tooth/teeth may have been traumatized by an accident or a tooth may have large fillings that can cause damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition and in some instances necessitate root canal treatment.
7) Orthodontic appliances are composed of very small parts connected together. They can be accidentally swallowed, aspirated, or could irritate or damage the oral tissues. Cheeks and lips may be scratched or irritated by loose or broken appliances.
8) Abnormal wear of teeth is possible if a patient grinds the teeth excessively.
9) Oral surgery, tooth removal or orthognathic surgery may be necessary in conjunction with orthodontic treatment, especially to correct crowding or jaw imbalances. You should discuss the risks involved with treatment and anesthesia with your general dentist or oral surgeon before making your decision to proceed with this procedure.
10) The total time required to complete treatment may exceed the estimate. Excessive or deficient bone growth, poor cooperation in wearing the appliances or elastics the required hours per day, poor oral hygiene, broken appliances, missed appointments and other factors can lengthen the treatment time and can adversely affect the quality of the end result.
11) Some patients may have allergies to component materials that may result in adverse reactions and require alteration or cessation of orthodontic treatment with corresponding limits on success of therapy.
12) Due to the wide variation in the size and shape of teeth, or missing teeth, achievement of an ideal result (for example, complete closure of space) may require restorative dental treatment. You are encouraged to ask questions about additional dental care.
13) In cases where there is an unerupted or impacted tooth, there is a possibility that the act of pulling the tooth into the arch can cause damage to the roots of the adjacent teeth. There is also the possibility that the tooth may be “ankylosed” or stuck and not move into the arch, even with orthodontic treatment.
14) Orthodontic treatments vary between practitioners. Transfer will likely increase treatment fees, may involve changes in payment policies, and may change your treatment and/or appliances. When you transfer to a new orthodontist, your treatment time is often extended by the process of transfer.
For the majority of patients, orthodontic treatment is an elective procedure. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present oral condition. Alternatives to the orthodontic treatment for a particular patient depend on the specific nature of the individual’s orthodontic problem. Alternatives could include, but not be limited to:
1) Extraction versus treatment without extraction
2) Orthognathic surgery versus treatment without surgery
3) Possible prosthetic solutions
4) Possible compromised approaches
Please discuss possible treatment alternatives or other treatment questions with your orthodontist.
Acknowledgement of Informed Consent
I hereby acknowledge that the major treatment considerations and potential risks of orthodontic treatment have been presented to me. I have read and understand this form and also understand that there may be other problems that occur, and that the actual results may be different from the anticipated results.
Dr. Langford has discussed the orthodontic treatment with me. I have been asked to make a choice about the treatment. I have been presented information to aid in the decision-making process and I have been given the opportunity to ask all questions I have about the proposed orthodontic treatment and information contained in this form.
Consent to Undergo Orthodontic Treatment
I hereby consent to the making of diagnostic records, including xrays, before, during and following orthodontic treatment, and to Dr. Langford and his staff providing the orthodontic treatment described by the Doctor. I fully understand all of the risks associated with the treatment.
Authorization for Release of Patient Information
I hereby authorize Dr. Langford to provide other health care providers with information regarding the orthodontic care as deemed appropriate. I understand that once released, Dr. Langford and staff have no responsibility for any further release by the individual receiving this information.