Form- Parrock consent forms

Consent forms

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Name*

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Treating Dentist Name

Consent Form Type*

Periodontal treatment consent

As with all medical procedures, there are risks and potential complications associated which you must be aware of before you proceed with treatment:

Periodontal treatment is not 100% successful all of the time, even if all parts of the procedure go as planned. Therefore some teeth that have undergone this procedure will require further treatment or may require extraction.

Do you consent to the treatment : Periodontal Consent Form*

Yes

Signature

Date of Signature

Tooth Preparation procedures consent

Tick the boxes to confirm the points have been discussed with you by the dentist and you have read, understand and accept the risks, benefits and points mentioned as follows:

I have been given all treatment options including no treatment, extraction(s), and restorations and have opted for: filling(s)/ Crown(s)/ Bridge(s) / Veneer(s) or……… I understand that having fillings, crowns/ bridges or veneers carries certain risks and these are outlined as follows:

Crowns/veneers/bridges and fillings are not always 100% successful, even if all parts of the procedure going as planned. The tooth may not have enough strength left prior to this procedure for good long term results. Decay and any previous work may have already irritated the nerve which could result in toothache in the future. Therefore some teeth that have undergone this procedure will require root canal treatment in the future, or may require extraction.

Do you consent to the treatment*

Yes

Signature

Date of Signature

Teeth Whitening Consent

Signature*

Date of Signature

Extraction Consent

I understand that there may be an alternative to the extraction of teeth. After considering the various options discussed with me however, I have chosen an extraction. I understand that there are sometimes complications that can occur, despite all efforts to the contrary as a result of the extraction(s) which include but are not limited to:

Do you consent to the treatment : Extraction Consent Form*

Yes

Signature

Date - Signature

Denture Consent

Do you consent to the treatment : Denture Consent Form*

Yes

Signature

Date - Signature

Root Canal Patient Consent Form

Informed consent to treatment

Do you consent to the treatment*

Yes

Signature

Date of Signature

Dental Implant Pre-treatment Consent

Treatment procedure proposed

Additional procedures

Extraction

Grafting

Temporary restoration

Treatment options, advantages and disadvantages:

The options were discussed in detail with you for replacing the missing teeth which included:

(Tick boxes if discussed with patient)

1. No treatment and accept situation as it is including possible poor appearance and chewing-this was not an option for you as you requested replacement to improve your chewing and / or appearance for more confidence smiling.

2. Restorative options The remaining tooth was agreed to be restorable with a guarded to poor prognosis and we agreed to remove it.

3. An Acrylic denture. I advised this is removable, can compromise function as it can be loose and sore to gums when eating, difficult for some patients to tolerate due to bulk or gag reflex, may need to use adhesive, further teeth can be added, removable and can be bad for gums and adjacent teeth as accumulates plaque which can cause gum disease and decay of adjacent teeth, ongoing costs discussed as may need to be replaced regularly. You did not want this option as you wanted a fixed option.

4. A Chrome denture -This is chrome/metal at the back, removable, more tolerable, stronger and less palatal coverage than acrylic dentures, can have better retention with clasps and rest seats, further teeth can be added only if designed for this, lighter, costs more, more hygienic than acrylic). You did not want this option as you wanted a fixed option long term.

5. Fixed bridgework- we discussed that it would be fixed, can be done relatively quickly compared to implants, relies on adjacent teeth which need extensive preparation, periodontal/gum status must be excellent, preparation of teeth has several risks- risk of devitalisation, debond risk, risk of fracture of remaining tooth which require extraction if extensive, risk of gum recession and poor appearance, costs similar to dental implant tx. You did not want this option due to the risks and damage to adjacent teeth.

6. Adhesive (sticky) bridge work- this is relatively simple and quick to make, very conservative and has been shown to fare well when the load is low long term, there is a risk of de-bonding , the greyness of the metal wing can show through teeth giving a poor appearance, the cost is similar to other bridgework . You were not keen on this option long term due to the risk of de-bonding. But you may consider this if you require a temporary restoration.

7. Dental implant treatment: We discussed that this is usually fixed, independent of other teeth, requires certain criteria to be met i.e. sufficient bone , higher short term costs, only option other than healthy teeth that can maintain the jaw bone and prevent the mouth from sinking in over time. It has a long lasting long-term prognosis to replace missing teeth in many good quality studies, it is an expensive option, has a long treatment time, requires adequate bone volume. There are possible risks of damage to anatomical structures where the implant is placed- to the upper jaw sinus in the top back regions, in the lower back region the risk of damage to lower jaw nerves supplying the lower lip and chin areas and temporary nose bleeds and altered sensations in the top front region. A Ct scan is required in most cases for accurate planning and assessment of bone volume for implant placement and anatomical structures. The scan may show it may not be possible to place implants and you may require another option. Also we discussed a higher risk of failure if immediately placed at time of extraction or immediate loading, Also the possibility you may need a bone graft of pig and cow origin or from elsewhere in your mouth as with an immediate implant or where there is bone loss or a thin ridge or when infection present. You may require a soft tissue graft from the palate if the gum is thin or recedes. Also there is a long term risk of gum and bone loss over time exposing the metal which may require further tx at further cost to you for aesthetic reasons and the possibility of implant loss or failure over time which may need replacing at further cost and time to you. There is a higher risk of these in high risk patients who smoke, have poorly controlled diabetes, who grind or overload there teeth, who do not attend regular to get their mouth checked by our practice after treatment at the suggested recals. The implant is guaranteed for 1 year after placement and has been found to have a 10 year survival of 95+% in good quality studies in most healthy adults who do not have any high risk factors and who attend for maintenance tx by the dentist every 6 months and hygienist treatment every 3 months at our practice as advised from thenoutset. The restoration and components attached to the dental implant may loosen or fracture and may need tightening, repairing, refixing or replacing over time at further cost and time to you.

Risks and benefits of treatment discussed as follows:

We discussed the risks and benefits of the implant treatment options in detail as follows:

• There are specific HIGH RISK FACTORS associated with high failure of dental implants and also natural teeth including parafucntional habits such as grinding and clenching and biting foreign objects, diabetes especially poorly controlled, smoking, gum disease and Bisphosohonate medication and other possible medical or specific bone conditions which could adversely affect the health of your gums and bone supporting your teeth and dental implants. Good clinical studies have shown approximately 50% less success with these conditions and habits compared with healthy individuals who do not have any risk factors especially who smoke, have diabetes or grind their teeth. We cannot guarantee the success of your dental implant treatment if you have any of these high risk factors or conditions as there is an unknown element that could lead to their failure which you accept and may lead to the need for further treatment requiring further normal costs and time. You accepted these risks. Our personal experience is a very high percentage of patients requiring dental implant treatments due to tooth loss or missing teeth smoke or suffer from at least one of these conditions or habits and we routinely treat them satisfactorily with dental implants.

• Immediate implant placement after any tooth extractions would only be possible if the sockets and bone are healthy after careful extraction otherwise we will need to leave the area up to 6 months to heal with or without a temporary restoration.

• For immediate implant cases we advise some graft material is used of pig or cow origin to reduce bone and gum loss in time.

• Also we agreed to consider immediate loading of the implants only after careful assessment deems it suitable and if good primary stability of implants is achieved and a favourable occlusion with reduced overloading / grinding risk is present. Otherwise we agreed not to do this where there is a higher risk of failure and consider placing healing abutments over the implants or leaving the implants under the gum to heal and leave the gaps un-restored or restore them with a temporary restoration such as a denture or adhesive bridge where suitable on assessment.

• The patient accepts there is a higher risk with immediate placement and loading of implant failure and complications requiring further treatment incurring further normal costs and time.

• We also discussed the risks of placing lower posterior implants including permanent and temporarily IDN nerve damage and numbness sensation of the lower lip and chin/cheek in that area. The risks as we discussed are reduced with implant planning and placement using an accurate CBCT scan and placing shorter dental implants.

• Also we discussed the risks of damage to adjacent teeth when placing dental implants.

• Also we discussed the risks of placement of dental implants in the top front area including perforation of the nasal floor which could lead to temporary nose bleeds and altered sensations which usually resolve by themselves.

• Also we discussed the risks of perforation of the upper jaw sinuses for upper posterior areas which could lead to acute or chronic symptoms including sinusitis and pain swelling and bruising which could lead to implant and any graft failure. Some of the complications may require specialist treatment separate to dental treatment at the practice. The risks as we discussed are reduced with implant planning and placement using an accurate CBCT scan and placing shorter dental implants.

Restorative phase

• The final restoration work will usually start after the implants have healed or sometimes sooner. This is usually 4-6 months after implant surgery and involves several appointments before the final work is fitted. (Usually 2-6 appointments or more depending on the complexity.)

• We always aim for the final restoration to be retained to the implant by a screw if possible so it can easily be tightened and accessed if required. If this is not possible for function or aesthetics it will be glued to the implant post by a temporary or permanent cement.

For full jaw or mouth work such as all on 4/ all on 6 treatment:

● In full Jaw and mouth dental implant work the final restoration takes some time to settle in for the tongue, cheeks and lips and speech such as lisping to adjust and patience is required during this adjustment phase which can take 6 to 12 months from being fitted.

● We design the final fixed full jaw bridgework if fitted to have a gap between it and the gums for cleansibility and hygiene of the implants to avoid failure. This may take some adjustment as food may accumulate but it is easy to remove with an airflosser if advised and tepe brushes as will be shown. Any altered senstion to your tongue and altered speech will take time to adjust to usually upto 6 to 12 months from being fitted.

● The final bridgework material can be metal-ceramic or metal-acrylic and both have their advantages and disadvantages.

● Metal- acrylic bridges are very pleasing in appearance and softer to the bite and jaw joint. They can be more prone to fractures and breakages being softer than metal-ceramic bridges especially in people who grind their teeth however they are easy to repair and not as costly as metal- ceramic bridgework. You would need to wear the first temporary bridge made for you during the repair period.

● They can also stain excessively over time requiring polishing and after a few years an overhaul of the acrylic on the bridge may be required which can be costly.

● Metal ceramic bridges have the best appearance and are usually stronger and thinner than metal acrylic bridges. However they are at risk of chipping and fracturing which is very costly to repair in the lab and you would need to wear the first temporary bridge made for you during the repair period.

• I understand that once I have completed my final try in appointment or approved the appearance of the final teeth e.g. in temporaries, and possibly wax try in stage, my restoration work is sent to the lab for fabrication in preparation for my final fit appointment. No changes can be made to the restorations past this point. I have confirmed I am happy to proceed. If, in the event that I am unhappy with the restorations once I have my final fit, I will be liable to cover the costs of the lab fees and surgery time incurred, and any further costs incurred to make any changes, should I request a refund or any modifications you accept these costs.

Fitting of final implant restorations and dental implant health discussion

• We discussed the fitting and hygiene around the implants. I advised there is a low risk of the failure of an implant after the first year of function as long as you do not have any high risk factors and your health both general and around the implants is maintained and no excessive forces are exerted. The dental implants are guaranteed by the practice in patients with NO HIGH RISK FACTORS for the first year from placement after which time all normal fees apply for any further treatment required. Joining our practice membership scheme, The Platinum Plan is mandatory for this limited guarantee.

• Excessive forces such as grinding, clenching or chewing hard objects and sometimes normal wear and tear over time may result in fracture or debonding of restorations and component parts or loosening of screws retaining parts which may require further treatment at additional cost to you.

• I advised as there is no nerve supply to implants to indicate overloading it is common to use screw retained work or cement the final work with a semi permanent or provisional cement so that components like screws and the implant head can be accessed and tightened and checked if required without damaging the final restorations to access them. Sometimes it is not possible to use screw retained restorations especially at the front of the mouth for aesthetic reasons so the screw hole is not visible and in those cases where implant placement is not ideal and governed by the remaining bone.

The semi permanent or provisional cement used (such as tempbond or premier implant cement) is strong when biting down but pulling forces such as from sticky foods like toffees can de-bond the final restorations which can then require re-fixing at additional costs to you. These type of foods should be avoided to reduce this risk. If a permanent cement is used such as Fuji plus and internal components loosen the final restorations will require grinding to access the components and screw then the restoration and occasionally even the dental implant may require replacing at additional cost and time to you.

The choice will be given to you but it is advisable to use a semi permanent cement where possible and only consider a more permanent cement if the work continually de-bonds for any reason or after the first year. You accepts the risks involved with this.

Platinum Dental plan details:

• After completion of treatment I recommended that you attend the surgery 6 monthly with the dentist to monitor the implants, your mouth and soft tissues and your teeth and also attend for hygiene care every 3 months to maintain a high standard of hygiene and gum health around the dental implant and restoration and natural teeth. All of this is included with the Platinum Dental Plan.

• Terms and conditions and exclusions of any guarantee of the dental implant treatment apply which we discussed in detail and especially excludes people who have high risk factors described earlier, such as smokers, diabetics, parafunctional habits like grinding and clenching, very ill patients in poor health, and those patients who do not follow our recall attendance advice to see the dentist and hygienist, and normal wear and tear and changes in medical conditions. I also advised you to see our website and leaflet which has the full details and terms.

I agree and accept all the risks*

Yes

Signature*

Date of Signature

Botulinum Toxin Therapy for Wrinkle Correction

What is Botulinum Toxin?

Botulinum toxin is a bacterium that blocks the release of acetylchline, the substance responsible for transmitting electrical impulses that elicit muscle contraction. In medicine, botulinum toxin is injected directly into hyperactive muscles. It has been safely and effectively used for treatment of strabismus (cross-eye) and blepharospasm (lid spasm) since the early eighties.

How does botulinum toxin work?

Hyperactivity of the facial expression muscles often results in the development of deep frown lines, forehead lines and/or crow’s feet. Injecting botulinum toxin into the affected area temporarily paralyzes the underlying muscles responsible for wrinkling, giving the face a more relaxed and pleasant appearance. The wrinkles become smoother or disappear altogether.

When and how long does botulinum toxin work?

The initial effects of treatment become visible within 48 to 72 hours. The maximum effect is reached in about 1 to 2 weeks. Your facial expressions will become more relaxed but by no means mask-like. The overall result is very natural. The effect of treatment generally lasts 4 to 6 months. Re-treatment is then required.

Potential adverse effects (side effects)

Botulinum toxin injection is generally a safe and effective treatment method. Nevertheless, certain side effects can occur but, like the intended treatment effects, they are mostly reversible. At this appointment, you will be informed about the potential side effects of botulinum toxin therapy, contraindications to therapy, and potential drug interactions.

Potential side effects

Bruising or swelling at the injection site
Slight feeling of nausea
Tiredness, pain in the arms and legs
Temporary drooping of the eyebrow or upper eyelid
Brief visual disturbances
Dryness of the eyes
Skin rash
Itching
Allergic reaction
Dry mouth
Muscle atrophy

Contraindications

Pregnancy
Breast-feeding
Myasthenia gravis
Lambert-Eaton syndrome
Blood coagulation disorders

Drug interactions

Drug interaction can occur when botulinum toxin is used concomitantly with other medications. Since these medications can alter the effects of botulinum toxin, you must ensure that your doctor is aware of any current medications you are taking, especially

Aminoglycoside antibiotics
Anaesthetics
Muscle relaxants

Signature*

Date of Signature

X-Ray and Ct scan consent

Signature*

Relationship to patient (if next of kin)

Date of Signature

All on Four Consent

You are going to have a procedure involving the placement of Implants. Therefore, it is important that you fully understand the nature of the surgical procedure and the most common risks and side effects. Surgery is not an exact science, and this Consent Form does not list all of the possible complications that can be associated with the procedure. In addition, the Implant Surgeon cannot guarantee the results of the Implant procedure.

Advantages & Disadvantages of Implants
Potential Risks of Implants
All-on-4™ Implants – What to Expect
All-on-4™ Implants – Pre-Operative Instructions
All-on-4™ Implants – Post-Operative Instructions
Replacement of Failed Implants

a) Post-operative discomfort, swelling and/or bruising which may necessitate several days of home recuperation.

b) Heavy bleeding which may be prolonged and may require treatment.

c) Injury to adjacent teeth and/or fillings.

d) Post-operative infection which may require additional treatment.

e) Restricted mouth opening for several days or weeks.

f) Creation of an opening into the nasal sinus (a normal cavity situated above the upper back teeth), requiring additional surgery.

g) Bruising of the face and/or jaws.

h) Development of a persistent opening between the sinus and the mouth.

i) Development or worsening of jaw joint symptoms.

j) Permanent or temporary numbness or altered sensation of the lip, tongue and/or cheeks.

k) Injury to the nerve underlying the teeth resulting in pain, swelling, numbness and/or tingling of the teeth, gums, lip, chin, cheek and/or tongue on the operated side. This may persist for several weeks, months or – in very rare instances – permanently.

l) Bleeding from the nose, which may occur soon after the surgery or subsequently.

m) Inhalation or swallowing of small Implant components during surgery, necessitating referral to a hospital for x-rays to confirm the position of the component and arrangement needing to be made for removal of the component unless it passes through naturally.

n) Need for additional surgery.

ACCEPTANCE FOR TREATMENT

You should only consider Implant treatment if you can maintain a high level of oral hygiene and plaque control. There should be no medical conditions that contraindicate the procedure. It is important to inform your Dentist immediately of any changes to your general health or medical condition.

If there is anything that you do not understand about the explanation, or if you want more information, you should ask your Dentist before signing.
Please check that all the information on this Consent Form is correct. If it is, and you understand the explanation letter, then sign below.
A copy of this Consent Form and accompanying letter will be kept with your dental records.

If you wish to proceed with the treatment as described, you will need to complete your name and sign below. Please retain one copy and return the other prior to the start of your treatment.

Signature

Date of Signature

Composite bonding Consent

Dental Bonding is a technique that has been used in cosmetic dentisry for many years and can transform your smile in just a single visit. The process involves the skillful use of the correct amount and colour of a “dental composite”, which is a mouldable material with a paste-like consistency made from acrylic resins and a variety of fillers, depending on the type used. Dental Bonding is an option that can be considered:

To repair decayed teeth (composite resins are used to fill cavities)
To repair chipped or cracked teeth
To improve the appearance of discoloured teeth
To close spaces between teeth
To make teeth look longer
To change the shape of teeth
As a cosmetic alternative to amalgam fillings
To protect a portion of the tooth’s root that has been exposed when gums recede.

Advantages

Dental bonding is among the easiest and least expensive of cosmetic dental procedures. Unlike the veneers and crowns, which are customised tooth coverings that must be manufactured in a lab, bonding usually can be in one visit. Another advantage, compared with veneers and crowns, is that the least amount of tooth enamel, if any, if required to be removed. Also, unless dental bonding is being performed to fill a cavity, anaesthesia is usually not required.

Disadvantages

Although the material used in dental bonding is somewhat stain resistant, it does not resist stains as well as porcelain. Another disadvantage is that the bonding materials do not last as long nor are as strong as other restorative procedures, such as crowns, veneers, or onlays. Additionally, bonding materials can chip and break off the tooth

Aftercare

Bonded teeth do not require special care. Simply follow good oral hygiene practices. Brush teeth at least twice a day, floss at least once a day, and see your dentist for regular professional check-ups and cleanings. Because bonding material can chip, it is important to avoid such habits as biting fingernails, chewing on pens, ice or other hard food objects; or using your bonded teeth as an opener. If you do notice any sharp edges on a bonded tooth or if your tooth feels odd when you bite down, call Parrock Dental for further advice on 01474 537191

We will guarantee the placement of your composite bonding for the first 12 months after treatment with your understanding of all the above information and your acceptance of good oral health habits. We highly recommend you attend our practice every 6 months to see one of our dentists to examine and ensure the health of your teeth and mouth and composite bonding and check your bite and also to see our hygienist every 3 months for hygiene and air polishing care to maintain the gum health and remove any stains and deposits from your teeth and bonding.

We cannot offer any guarantee of your dental treatment if;

If you fail to follow any of our advice given to you during or after treatment.
If you do not attend every 6 months for a dental examination and see our hygienist every 3 months for hygiene and air polishing treatments to remove any stains and deposit build up on your teeth and composite bonding.
If you grind your teeth and do not wear a night guard provided by our practice.
If there are any chips or breakages due to overloading caused by loss of back chewing teeth or grinding of teeth or overloading habits such as nail biting.

Staining of your bonding is normal and can happen and is dependent on your diet and dental habits. Composite Bonding may need polishing over time to remove some stains and sometimes the bonding will need replacing or redoing and this will be at further costs to yourself and normal charges will apply. To reduce staining we highly recommend you see our hygienist every 3 months and have air polishing and hygiene care.

Joining our Platinum Dental plan is the most cost effective way to maintain your bonding as it covers all dental examinations (twice a year), hygiene appointments (4 times a year) for dental hygiene treatment (excludes air polishing), and also includes whitening top up syringes and x-rays to check your teeth.

We would be grateful if you could read the below and tick which photo/video disclosure you would be happy to consent to:*

I hereby give consent for my whole face to be shown on photography and videography produced by Parrock Dental for patient communication, promotion and dental research

I hereby give consent for my whole face to be shown on photography only produced by Parrock Dental for patient communications, promotion and dental research

I hereby give consent for my anonymised (smile only) to be shown on photography produced by Parrock Dental for patient communications, promotion and dental research.

I do not consent to any photography or videography to be used by Parrock Dental to help in patient communication, promotion or dental research.

Signature

Date of Signature

Information And General Consent For Zygoma/ Full Arch Implant Procedure

You are going to have a procedure involving Zygoma Implants. Therefore, you should understand the nature of the operation and most common risks involved. Surgery is not an exact science, and this consent form does not list all the possible complications that can be associated with the procedure. In addition, the surgeon cannot guarantee the results of the Implant procedure(s).

The Surgical procedure requires incision and reflection of the tissues (gums), removal of the bone to expose the sinus cavity, lifting of the sinus membrane, placement of Zygoma Implants and closure of the wound with stitches. I have been informed of possible alternative methods of treatment, if any. The following stages of the treatment have been explained to me.

Contouring and reduction of bone and gum, will be carried out to improve the fit, function and cosmetic appearance of your bridge.
A prototype bridge may be in place for three to six months, there is always a small chance that immediately fixing the prototype bridge may not be possible on the day of your surgery, in which case you will be provided with a removable denture.
A final bridge will be placed after approximately a minimum of three to six months of healing.

This operation will be followed by a degree of discomfort, swelling, nasal and/or sinus stuffiness, and pain that may require 7 to 14 days of recuperation on average. Complete resolution of all symptoms may take 6 weeks or longer.

The potential risks have been explained to me, and that in this specific instance such operative risks include, but are not limited to:

Postoperative discomfort, swelling and bruising which may necessitate several days of home recuperation.
Heavy bleeding that may be prolonged.
Injury to adjacent teeth and fillings.
Postoperative wound infection, sinus infection.
Restricted mouth opening for several days or weeks.
Opening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgery.
Postoperative bleeding, nosebleed.
Permanent or temporary numbness or altered sensation of the lip, tongue or cheeks.
Discolouration (black/blue) of face or jaws
Development of an opening between the sinus and the mouth.
Development or worsening of jaw joint symptoms.
This may persist forseveral weeks, months or, in remote instances, permanently.
Soreness of the corners of the mouth.
Inhalation or swallowing of small implant components during the surgery may occur, necessitating referral to a hospital for a chest x-ray to confirm the
Need for additional surgery.

If any unforeseen conditions should arise in the course of the operation, calling for a doctor’s judgement or for procedures in addition to or different from those now contemplated, I request and authorise the doctor to do whatever he may deem advisable.

No guarantee or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. Due to individual patient differences there exists a risk of failure, relapse, selective retreatment or worsening of my present condition despite the care provided.

If I am a smoker, grind my teeth, have diabetes, especially uncontrolled, or suffer with advanced gum disease I am at higher risk of implant and teeth failure and this means the success of your treatment cannot be guaranteed and if complications arise further costs and procedures may be required and you accept this.

Signature

Date of Signature

Terms and Conditions for £100 off Dental Treatment Offer

The £100 offer is valid for new patients only, who have not previously received dental treatment plan from the dental practice.
The offer is valid on a single treatment plan for Dental Implants or Invisalign only.
The offer cannot be used in conjunction with any other offers, discounts, or promotions.
The offer is subject to availability and may be withdrawn or amended at any time without prior notice.
The offer is only valid for a limited time period, as specified by the dental practice, and will end on The offer is valid until Friday 28^th July.
To redeem the £100 off offer, patients must mention the offer at the time of booking the appointment and present a copy of the voucher, where applicable.
The offer is non-transferable and cannot be exchanged for cash or other services.
The offer does not cover any additional fees or charges that may be incurred during the course of the treatment.
The dental practice reserves the right to refuse or terminate the offer at any time, without prior notice or explanation.
The offer is only available to patients who are over 18 years of age.
The offer applies to Invisalign or Dental Implant treatments only.
The offer is subject to the dental practice's assessment and approval of the patient's suitability for the treatment.
The offer may not be used to cover emergency treatments or other urgent dental care needs.
The offer is not valid for NHS treatments or for patients who are exempt from NHS charges.
The offer is subject to the dental practice's standard cancellation policy.

Signature

Date of Signature

Patient consent for Invisalign® orthodontic treatment

Invisalign is a series of thin, clear plastic, removable appliances (aligners) that move your teeth in small increments from their original position to a more aligned position. After a dental exam and x rays, a series of custom aligners are prescribed and made to fit you and monitored throughout the course of wear by an orthodontic therapist and dentist.

Benefits: Aligners offer an aesthetic alternative to conventional braces as they do not have the metal wires or brackets associated with conventional braces. Aligners are nearly invisible so many people won’t realise you are in treatment. No metal or wires usually means less time is spent at the dental practice having adjustments made. Tooth movement can be visualised through the Clincheck software. Aligners allow for normal brushing and flossing tasks that are generally impaired by conventional braces. You cannot eat whilst wearing removable appliances as this can damage your teeth and aligners/retainers.

This patient agreement contains important information about your treatment.

I understand that my doctor has recommended Invisalign treatment to improve the alignment of my teeth. While this treatment can enhance my smile, it also has limitations and potential risks. I agree to the following terms:

Treatment aims: We aim to improve the alignment of my upper and lower teeth, excluding any bite or jaw issues. Achieving a perfect result is not always possible due to these factors and the complexity of the treatment. You accept this important limitation.
Treatment exclusions: We have agreed not to treat specific conditions that may require jaw surgery or complex additional appliances and will only achieve results predictable with Invisalign braces.
Additional risks and issues: I have been informed of specific risks and issues associated with the treatment, as discussed separately such as root resorption, loss of teeth vitality, gum recession, relapse of teeth.
Conditions that void guarantees: Failure to maintain adequate oral hygiene, not wearing the braces as advised, not attending scheduled review appointments or any braces appointments for longer than 4 months unless agreed with your dentist or see a dentist regularly for check-ups may adversely affect your dental health and treatment, and will lead to the termination of Invisalign treatment.
Treatment duration and costs: Invisalign treatment typically lasts around 2 years, but it may take longer for complex cases and you accept this. If I decide to end the treatment early, I accept the results achieved and will be responsible for any further costs if I choose to restart the treatment.
My Invisalign course of treatment is valid for 2 years only and includes 3 sets of additional aligners at no extra cost. Any treatment beyond this point may result in an additional charge.
Special occasions and attachments: Removing attachments for special occasions and then replacing them will incur additional costs and prolong the treatment time and we do not advise this.
Lost aligners: If I lose an aligner, I should use the previous one and notify the doctor promptly. Ordering a replacement aligner may take a few weeks and incur additional costs.
Retainers and aftercare: I understand that I must wear retainers for life after completing Invisalign treatment to prevent relapse. Fixed and removable retainers are recommended, along with regular dental check-ups and hygiene visits. Some movements are more.prone to relapse even when wearing retainers and you accept these risks such as space closures and open bite closures and movements with severe rotations or malpositioned teeth. Further costs will apply for treating relapsed cases and you accept these risks.
Importance of follow-up appointments: Regular check-ups every 6 months and hygiene visits every 3 months are crucial to maintain dental health and monitor the Invisalign result. Failure to attend recommended appointments will result in the loss of aftercare support.
Device description: Invisalign aligners are clear, removable appliances that gradually move the teeth. Customized aligners are produced based on the doctor's prescription and treatment plan.
Procedure: The treatment involves examinations, impressions or scans, treatment planning, and the use of a series of aligners. Aligners should be worn for 20 to 22 hours per day, switching to the next aligner every two weeks or as directed by the doctor.
Benefits: Invisalign aligners offer aesthetic benefits, as they are nearly invisible. They allow normal brushing and flossing and do not have the metal components associated with traditional braces. Invisalign treatment may improve oral hygiene and gum health.
Risks and inconveniences: Invisalign treatment carries risks such as longer treatment time, dental tenderness, irritation to gums and lips, tooth shifting after treatment, oral health issues, temporary speech changes, increased salivation or mouth dryness, attachment-related issues, and other potential complications.
Informed consent: I have read and understood the information provided about Invisalign treatment, including its benefits, risks, and alternatives. I have discussed any concerns with my doctor and consent to the treatment. I understand that the outcome cannot be guaranteed, and Align Technology, Inc. does not provide medical or dental services.
Medical records and privacy: I consent to my doctor collecting and using my medical records for treatment, customer service, and billing purposes. Align Technology and its corporate group may receive and store my records, ensuring data protection according to their Binding Corporate Rules.
Your treatment plan includes up to three sets of additional aligners. All further sets of additional aligners will be an additional cost of £100.00

Patient Responsibilities:

Clearly communicate your desired changes regarding your smile.
Maintain your oral health by following the provided brushing and oral hygiene instructions, scheduling hygiene visits every 3 months, and regular dental examinations every 6 months.
Inform the dentist about any previous tooth trauma that may have compromised a tooth's condition.
Attend all appointments on the scheduled day and time, giving at least 48 hours' prior notice for any cancellations to avoid a cancellation charge.
Understand that treatment duration may vary depending on factors like wear time compliance and tooth stubbornness.
Refrain from eating or drinking while wearing removable appliances to prevent damage.
Replace lost aligners with an additional charge after the first instance, as per the treatment fee guide.
Pay attention to the lifelong commitment of retention after Invisalign or any orthodontic treatment. Wear retainers as instructed and communicate any concerns about teeth position immediately.
Follow comfort and medical guidelines during treatment, including taking pain relief medication with consent, adjusting to speech changes caused by the aligners, and being open to mid-course corrections if necessary.
Minimize the risk of tooth decay, decalcification, and periodontal disease by reducing sugar intake and maintaining proper oral hygiene.
Be aware of potential injuries from aligners and report any discomfort or irritation for adjustments.
Understand that a tooth may become ankylosed (tightly bound) and treatment plans may change accordingly, leading to potential cost differences.
Inform the dentist about any jaw joint problems experienced during or after treatment.
Recognize that the stability of teeth is an ongoing process influenced by natural changes and wearing retainers enhances the final result. Ceasing retainer use may cause teeth to shift, requiring additional alignment treatment and costs.
Take note of potential enamel wear caused by excessive teeth grinding.
Discuss the impact of Invisalign treatment on existing dental bridges with the clinician.
Ensure the accuracy of the provided personal information on the form.

Invisalign Consent:

Acknowledge reading and agreeing to all the terms and conditions.
Agree to the proposed and explained procedure by the dentist.
Accept the use of the appliance, attachment, and Interproximal Reduction, if appropriate.
Understand the nature of the treatment, potential complications, and the importance of maintaining oral health through compliance with instructions.
Recognize the cosmetic nature of the procedure and the availability of alternative options.
Consent to additional procedures that are necessary for clinical reasons and will be explained beforehand.
Understand the validity of the Invisalign course for 2 years, including 3 sets of additional aligners at no extra cost. Any treatment beyond this period may incur an additional charge.
Inform the dentist about any procedures that you do not wish to be carried out without prior consideration.
Disclose existing medical conditions, infectious diseases, and recent medication history.
Seek clarification or more information from the dentist or treatment coordinator if needed.
Confirm the correctness of the information and sign the form.

Payments:

Choose a preferred payment method.
Settle any missed payments before the next appointment to receive the next set of aligners.
Arrange suitable alternative arrangements if the dentist is unavailable due to emergencies or personal reasons.

Other Treatment Fees:

Understand that any additional dental treatment apart from Invisalign will incur a separate cost.
This includes composite or edge bonding, veneers, crowns, or fillings, which can be performed at the current practice or another chosen location.

Keeping Appointments:

Notify the practice at least 48 hours in advance if unable to attend an appointment.
Failure to provide adequate notice or attend an appointment may result in a fee, payable before rebooking.
Contact the practice via telephone to cancel or re arrange any appointments.

Consent Summary:

The Invisalign treatment is valid for 2 years and includes 3 sets of additional aligners at no extra cost. Additional treatment beyond this may result in additional charges.
Patient responsibilities include outlining desired changes, maintaining oral health, attending appointments, informing the dentist of any tooth trauma, complying with treatment time and wearing instructions, and avoiding eating while wearing aligners.
Payment must be made prior to receiving the next set of aligners. Additional dental treatments outside of Invisalign are not included in the cost.
Retention is crucial to maintain the position of teeth, and patients are responsible for wearing retainers as long as they want to maintain the results.
During treatment, discomfort, speech changes, and the possibility of mid-course correction may occur.
Risks include tooth decay, decalcification, periodontal disease, injury from aligners, jaw joint issues, final stability of teeth, enamel wear, and potential damage to existing dental bridges.
Patients should inform the dentist about existing medical conditions and medications.

Retention:

Retention IMPORTANT: Retaining the position of your teeth after Invisalign or any orthodontic treatment will be a lifelong commitment. Forgetting to wear nightly, replace or care for your retainers will likely cause a relapse in the position of your teeth into an undesirable position. You and your clinician will only order or fix your retainers when both parties are satisfied with the position of your teeth. If you are not yet satisfied, it is imperative you communicate this. Retainers are designed to hold your teeth in their corrected positions after the braces have been taken off or you have completed your Orthodontic treatment. Orthodontic retainers are custom-made devices, that hold teeth in position after surgery or any method of realigning teeth. I understand I will need to wear retainers for as long as I would like to maintain the position of my teeth

Some movements are advanced and always more prone to relapse ( further unwanted movement) even when wearing fixed and removable retainers and this can happen in 5% of cases.

To monitor this it is essential we see you at the Practice every 6 months and the hygienist see you every 3 months to avoid voiding any aftercare cover from our practice.

We always recommend both fixed and removable retainers to prevent this as much as possible. We cannot measure removable retainer wear.

Retainers and aftercare: I understand that I must wear retainers for life after completing Invisalign treatment to prevent relapse. Fixed and removable retainers are recommended, along with regular dental check-ups and hygiene visits. Some movements are more prone to relapse even when wearing retainers and I accept these risks such as space closures and open bite closures and movements with severe rotations or malpositioned teeth. Further costs will apply for treating relapsed cases and I accept these risks.

You accept these risks and the need if this occurs for further braces treatment and possible new retainers at further normal costs to you.

Consent of treatment outcomes: and what will and will not be treated

⁠We will normally only align the top and bottom as applicable front 10 teeth (second premolar tooth to second premolar tooth left to right) and usually will not move back large molar teeth which can cause bite issues and extend the treatment time extensively as these teeth have been in this position for some time usually and are stable and are not usually visible.
⁠We cannot normally correct any jaw discrepancies that would require jaw surgery including over jets, overbites, under bites. We can usually only improve these by 4mm in some cases not all. You accept that the outcome result will be comprised if this relates to your case.
For lite cases treatment expires 2 years after your initial Invisalign dental examination and includes 2 additional sets of aligners to achieve our objectives. After this normal charges will apply.
For moderate cases treatment expires 3 years after your initial Invisalign dental examination and includes 3 additional sets of aligners to achieve our objectives. After this normal charges will apply.
For comprehensive cases treatment expires 5 years after your initial Invisalign dental examination and includes 5 additional sets of aligners to achieve our objectives. After this normal charges will apply.
The bite may need to settle after your braces treatment and this can happen after retainer wear at night time.
⁠You must wear a retainer to prevent relapse of your teeth after treatment which still can occur in approximate 10% of cases due to the teeth movements required. We recommend fixed and removable retainers being worn as recommended to prevent difficult movements which have a high risk of relapse from occurring after treatment. These include closing spaces, correcting large bite issues, rotated teeth and moving teeth up or down (extrusion or intrusion)
⁠You must attend at regular intervals for appointments and reviews and comply with virtual care arrangements to follow up and also follow all advice given to ensure the best result is achieved. Also you must not have any dental treatment done elsewhere we are not aware of which can affect the wearing of the braces and achieving your planned results. Any of the above will mean your braces treatment with Parrock Dental is ended due to noncompliance.
We will give you our chosen teeth whitening products and in house retainers complimentary as part of our Invisalign packages at our sole discretion and as applicable.
Further normal costs will apply for any services not included in your treatment plan such as hygiene services, composite bonding, exam appointments, emergency appointments, fixed retainers and replacement of lost or broken aligner and missed appointments including also noncompliance of advice given on your Invisalign instructions.
⁠This agreement is in addition to our other consent forms and agreements.

Signature

Date of Signature

Digital Smile Questionnaire

Your answers to the following questions will help us to understand your treatment goals and provide you with the best possible care.

1. Are you thinking about improving your smile for a special occasion?

Wedding

Birthday

Other, please provide details:

2. Have you previously had other cosmetic treatments, e.g. facial or dental treatments? If yes, please provide details

Yes

Name

First Last

Please provide details

3. Are you or have you been unhappy with any dental / cosmetic treatment received in the past?

Yes

Please provide details

4. What are your treatment goals? Please tick all that apply

Improve the colour of my teeth

Make my teeth straighter

Close gaps between my teeth

Repair broken, chipped, worn down teeth

Replace missing teeth

Replace discoloured fillings

Replace old crowns / veneers

Improve my gummy smile

Have a smile makeover

5. Which treatments are you specifically interested in? Please tick all that apply

Orthodontics (e.g. Invisalign and lingual braces)

Porcelain veneers / crowns

Implants / bridges

Teeth whitening

Facial rejuvenation (e.g. anti-wrinkle and tiller treatments)

6. On a scale of 1-10, with 10 being very happy, how would you score your smile today?

7. Are you anxious about having dental treatment?

Yes

Please explain why (e.g. drill, smell, previous experience, pain)

8. Do you have a budget in mind for your treatment?

Yes

Please provide details

9. Is anyone else involved in your decision to have treatment? (e.g. friend, partner, family member)

Yes

Please provide details (e.g. friend, partner, family member)

10. Do you have any concerns about your treatment? Please tick all that apply

Fear

Time

Distance to clinic

Not understanding treatment

Other, please provide details:

Please provide details:

11. How did you hear about Parrock Dental? (please tick one)

Recommendation

Google

Bing

Facebook

Finance

Embarrassment

Instagram

Other, please provide details:

Recommendation, please provide the name of your referrer

Other, please provide details:

Patient Name

Date

Patient Signature

An Invitation to be part of our Educational & Marketing Portfolio

Please tick below to confirm whether or not you would like us to; include identifiable / non-identifiable video(s) and photograph(s) of me / my son/daughter and written testimonial(s) in patient information and education resources including printed and online leaflets, brochures, CDs, websites, advertising, video hosting sites including YouTube, social media sites including Facebook, Instagram, Internet search engines including Google, and other Internet Publications, for perpetual and commercial use.

Video(s)*

Identifiable

Non-identifiable

Photograph(s)*

Identifiable

Non-identifiable

Treating Dentist Name

In cases where the patient has died or is incapable of giving consent, consent may be given by the next of kin. If the patient is under the age of 16, consent should be given by a parent or guardian.

Signature*

Photography Consent Signature

Date