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CONSENT FORMS

ORTHODONTICS CONSENT FORM

WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.

- Step 1 of 2

You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. *

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. *

Please read and initial the work to be done below, then read and sign the section at the bottom of the form.

EXAMINATION AND DIAGNOSTIC PROCEDURES I understand that the initial visit may require radiographs in order to complete the examination, diagnosis, and treatment plan *

DRUGS AND MEDICATION I understand that antibiotics, analgesics and other medications may cause allergic reaction causing redness, swelling of tissues, pain, itching and vomiting, and/or anaphylactic shock. I understand that the administration of local anesthetics may result in temporary or permanent paresthesia (numbness) of involved teeth, tissues, and associated structures. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain, and potential resistance to effect treatment of my condition. I accept these risks by consenting to the use of local anesthetics during my dental appointments. If I have a medical condition that necessitates antibiotic pre-medication before dental treatment, it is my responsibility to notify the dentist. I assume all responsibility for all medical consequences if the dental office is unaware of my need for pre-medication. *

CHANGES IN TREATMENT PLAN I understand that my treatment plan is only an estimate and subject to modification/changes depending on unforeseen or un-diagnosable circumstances that may arise during the course of treatment. I understand that any alterations to treatment may affect the total cost of my treatment and accept responsibility for any and all expenses regardless of third party involvement. *

ORTHODONTICS: I was given a final opportunity to make changes in my Orthodontics (including shape, fit, size placement, and color). The problems of wearing Orthodontic appliances have been explained to me, including looseness, soreness, and possible breakage. I understand that Orthodontic treatment requires multiple dental visits. The cost for this procedure is not the initial Orthodontic fee. *

We will repair/replace Orthodontic appliances at no additional cost during Orthodontic treatment and if there is a proven failure in Orthodontic restoration. For Orthodontic treatment and appliances, there is no warranty (initial *

I understand that dentistry is not an exact science; therefore, reputable practitioners cannot properly guarantee results. I acknowledge than no guarantee or assurance has been made by anyone regarding the dental treatment that I have authorized. I hereby authorize the doctors and staff members to proceed with and perform dental treatment as explained to me. *

PLEASE CHECK BOX BELOW *

• I UNDERSTAND AND AGREE THAT I AM FULLY RESPONSIBLE FOR ANY AND ALL DENTAL EXPENSES INCURRED AT DR. PRECILYN SILVESTRE-MELO
• I UNDERSTAND THAT MY DENTAL INSURANCE IS A CONTRACT BETWEEN THE INSURANCE COMPANY AND MYSELF. AS A COURTESY, MILPITAS SQUARE DENTAL WILL SUBMIT CLAIMS ON MY BEHALF TO MY INSURANCE COMPANY. REGARDLESS OF ANY THIRD PARTY OR INSURANCE INVOLVEMENT, I AM RESPONSIBLE FOR PAYMENT OF ALL DENTAL FEES.
• I UNDERSTAND THAT IF MY DENTAL INSURANCE CHANGES IT IS MY RESPONSIBILITY TO NOTIFY THE OFFICE
• I AGREE TO PAY ALL ATTORNEY’S FEES, COLLECTION FEES, OR COURT COSTS THAT MAY BE INCURRED TO SATISFY THIS OBLIGATION
• UNFINISHED TREATMENT: I UNDERSTAND THAT IF I ELECT TO DISCONTINUE TREATMENT AFTER IT HAS BEEN INITIATED, PRO RATA PAYMENT MUST BE MADE FOR PROFESSIONAL SERVICES TO THAT POINT. REFUNDS ARE NOT APPLICABLE TO RESTORATIONS AND PROSTHESIS. (refer to CALIFORNIA CIVIL CODE 1793.02 SEC. e-3).

CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of treatment and have received answers to my satisfaction. I voluntarily assume any and all possible risks including those as listed above. The fee(s) for service have been explained to me and are satisfactory. By signing this document, I am freely giving my consent to allow and authorize MILPITAS SQUARE DENTAL to render any treatment necessary and/or advisable to my dental conditions including the prescribing and administering any medications and/or anesthetics deemed necessary to my treatment. *

MILPITAS SQUARE DENTAL retains sole discretion to determine whether repair or replacement is appropriate. Warranties are subject to the following conditions and exclusions: *

• You must remain a patient of the practice and maintain your preventative care visits at our office at six (6) monthly intervals (Preventive care includes cleaning treatment, exams, x-rays and topical fluoride treatments) so we can ensure your underlying dental health.
• Recurrent decay due to poor patient oral hygiene is exclude.
• Orthodontic Restoration failure due to misuse (e.g., chewing ice, removing bottle caps with your teeth, accident damage, habitual damage such as nail biting etc.) is excluded.
• If there is a general illness occurring that has negative effects on the dental conditions (e.g., diabetes, epilepsy, osteoporosis, conditions after X-rays or chemo therapy) the warranty does not apply.
• Warranty is void if Orthodontic products is installed/reinstalled or serviced by anyone other than our practice.
• Change due to patient's perception of the aesthetics of the final case (referred to as preference towards the appearance of their teeth e.g., change in color, size, brand and type) after completion is excluded from the warranty.

We do not warrant (Orthodontic) from the date of replacement. We make no other warranties, including, but not limited to, an implied warranty of merchantability or fitness for a particular purpose. Standard post-delivery care (adjustments) is provided at no charge during the Orthodontic treatment period. We will not be liable for any loss or damages arising from this product, whether direct, indirect, special, incidental, or consequential, regardless of the theory asserted, including warranty, contract, negligence, or strict Liability. Suppose a course of treatment recommended by a dentist needs to be followed, or an alternative treatment course is chosen instead of the recommended treatment plan. In that case, a dental warranty will not cover the treatment. A dentist will indicate the applicability of the dental warranty concerning the course of treatment followed. In extreme rehabilitative or reconstructive cases, the dentition may be compromised to the extent that even complicated, high-quality prosthesis may have a guarded or poor long-term prognosis. In such cases, a standard warranty cannot be provided. A dentist will indicate the applicability or non-applicability of a warranty. We aim to provide you with the very best possible standard of dental care tailored to meet your specific needs and to do this in the most timely manner and with the utmost comfort. We want you to have a positive experience with us and gain the best treatment outcome. Your adherence to these preceding terms and conditions of treatment will allow us to provide the best care for you. *

PROCEDURE TO BE PERFORMED: *

PLEASE SELECT FROM THE DROPDOWN MENU

Date / Time *

Date

Time

Name *

First

Last

Signature *

ROTATE YOUR PHONE TO ENTER FULLSCREEN

PARENT/LEGAL GUARDIAN (if minor) *

Guardian Signature

WITNESS NAME *

ASK DENTIST / RECEPTIONIST / DENTAL ASSISTANT

WITNESS TO SIGNATURE *

Please ask only receptionist, dental assistant or dentist to sign this consent form

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