DR JOHN MAMUTIL | PHASE l | PHASE ll

Successful Orthodontic treatment is a partnership between the treating orthodontist and the patient. Your dentist and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve the desired results. While recognising the benefits of a beautiful healthy smile, you should also be aware that orthodontic treatment has limitations and potential risks. In some cases, there may be alternate treatment options to clear aligners. These options may vary with the individual’s specific problems and prosthetic solutions however you are encouraged to discuss alternatives with your orthodontist prior to beginning treatment.

This informed consent Agreement sets out the terms and conditions on which Brace5 will provide the treatment to the patient and the limitations and potential risks that the patient should consider before undergoing treatment. Please read them carefully and ask the staff should you have any questions prior to treatment.

1. Treatment Plan

Brace5 has provided the Patient with a Quotation letter which:

(a) categorises the treatment plan as Phase I or Phase II treatment;
(b) sets out:

(i) the treatment plan time
(ii)Estimated treatment time
(iii) fees associated with the treatment.

Brace5 has provided the Patient with a Quotation letter which:
1.1 Treatment (inclusive of all clinical procedures) will be performed by either the Orthodontist and Oral Health Therapists depending on the level and nature of the treatment plan. The Oral Health therapists provide care on behalf of the orthodontist.
1.2 If the treatment is Phase I treatment, the patient acknowledges that

(a) Phase II treatment may be required at a later date; and
(b) there will be additional costs associated with Phase II treatment.

1.3 The patient acknowledges that the Estimated treatment time is dependent on, and may be lengthened as a result of:

(a) The patient’s growth (including unanticipated growth of the patient’s teeth)
(b) The severity of the problem;
(c) Habits affecting the dentofacial structures.
(d) The level of patient cooperation; and
(e) Periodontal or other dental problems.

1.4 Significant skeletal disharmonies require treatment in conjunction with orthognathic surgery. There are additional risks associated with this surgery which the patient should discuss with their surgeon prior to starting treatment. Please be away that treatment prior to orthognathic surgery often only aligns the teeth within the individual arches and patients who discontinue treatment without completing the planned surgical procedures may have malocclusion worse than at the beginning of the treatment.

2. Payment

The patient agrees to pay Brace5 orthodontics the fees set out in the patient letter quotation in accordance with the periodic intervals and payment instructions set out in the quotation.

2.2 The Fees do not include:

(a) any treatment performed by the patient’s general dentist or any other dental, medical or health practitioner.
(b) costs for lost or broken appliances.
(c) Late cancellation fees.
(d) costs to transfer the patient to another location during treatment.
(e) additional credit card surcharges.

2.3 If the treatment is unduly prolonged due to reoccurring damage to the appliances or failure to comply with treatment instructions (i.e., Invisalign wear or elastics), Brace5 reserves the right to charge additional fees proportional to the additional time, materials and work required.

2.4 If the treatment is completed before the end of estimated treatment time set out in quotation, the patient will be required to pay the outstanding fees before the appliance is removed.

2.5 If the patient does not fulfil their obligation to pay the fees in accordance with the periodic interval and payment instructions set out in the quotation, Brace5 may:

(a) charge interest at the rate of 12% per month on any overdue amount
(b) refuse routine care until any outstanding payments are paid or brought up to date with an agreed payment plan; and
(c) refuse to remove the appliances until such time as the fees are paid in full.

3. Appointments

3.1 If a patient needs to schedule an appointment for a long duration procedure it will be scheduled during work/school hours.
3.2 Brace5 will try and accommodate the needs of the patient in order to minimise any time off work or school.
3.3 If the patient is unable to attend an appointment, the patient is to notify Brace5 with 24 hours advance notice so that a convenient time can be rescheduled.
3.4 If the patient doe does not comply with clause 3.3 Brace5 reserves the right to charge a late cancellation fee.
3.5 The patient agrees to receive a text messages and email correspondence from Brace5 in relation to scheduling appointments, practice alerts and treatment reminders.

4. Patient Responsibilities

4.1 The patient agrees to:

(a) Carefully follow any treatment instructions.
(b) Maintain good oral hygiene.
(c) Wear elastics and appliances as advised.
(d) Avoid food habits which can break or damage braces or buttons.
(e) Avoid losing or breaking appliance.
(f) Book and attend all scheduled appointments.
(g) Inform Brace5 of all parties involved in the patient’s treatment including, but not limited to, dentists, specialists, and general practitioners.

5. Patient Acknowledgement

5.1 The patient understands and acknowledges that:

(a) Excellent oral hygiene is essential during treatment.
(b) Inadequate or improper hygiene could result in cavities, discoloured teeth, periodontal disease and/or decalcification.
(c) Regular visits to their general dentist and regular check-ups are essential during treatment as patients wearing appliances have greater difficulty removing plaque from their teeth and are more prone to plaque related diseases.
(d) The patient can expect some an adjustment period and some discomfort due to the introduction of appliances.
(e) Brace5 orthodontics cannot guarantee that the patient will be completely satisfied with the results of treatment
(f) Brace5 cannot anticipate all complications or consequences that may occur as a result of treatment as the success of treatment depends on the patient’s cooperation in adhering to the responsibilities set out in clause 4.
(g) Failure to attend any appointments may delay progress in treatment.
(h) Brace5 may send the patients’ medical information to the patient via email, unless requested otherwise.
(i) There are a number of risks and limitations (please see schedule 1.)

5.2 If this agreement is entered into by the patients parent of guardian, the parent or guardian warrants that it has the authority to enter into this agreement on behalf of the patient and the parent or guardian agrees to indemnify Brace5 from any and all claims, costs, suits, demands, liabilities and expenses incurred by Brace5 arising from or in any way connected to any misrepresentation made by the parent or guardian in entering into this agreement on behalf of the patient.

6. PRIVATE HEALTH FUND

6.1 If the patient belongs to a health fund, they agree to contact the private health fund the determine the benefits to which they are entitled.
6.2 The patient acknowledges that Brace5 has no control or responsibility with regards to the benefits paid under a private health fund and Brace5 is only required to provide the private health fund with necessary information regarding the treatment being undertaken.

7. PATIENT TRANSFER

7.1 If during the treatment, the patient moves location and/or transfers to the care of another practitioner, the patient should advise Brace5 of such as soon as reasonably practicable and sign an authority to release medical records from after which Brace5 will (as necessary) provide

(a) A patient transfer report on the progress of the treatment to the new practitioner.

8. REFUSAL OF TREATMENT OR SURGERY

8.1 Brace5 is not liable for any consequences which arise after the patient refuses to undergo or seeks to modify or modifies the proposed treatment plan (including Phase II or any other recommended treatment or proposed orthognathic surgery) as entailed in the letter to patient, quotation or in any other discussion between the patient and Brace5.
8.2 The patient agrees to accept liability to which arising after the patient refuses to undergo or modifies the proposed treatment plan, including, but not limited to, complications which arise in any future treatment after the patient’s decision to refuse, modify or terminate the treatment.

9. PATIENT FILE MANAGEMENT

Brace5 agrees to comply with its privacy obligations pursuant to the Australia Dental Code of Conduct and the privacy act 1988 when maintaining, using, and disclosing the patient’s file.

10. MEDIA RELEASE

The patient grants permission to Brace5 to use any photograph, video and/or other non-identifying multimedia material of the patient in media publications including but not limited to videos, learning materials, social media, website, and seminars/webinars.

11. SUSPENSION OF TREATMENT

If the patient fails to pay the fees pursuant to clause 2 or any other alternative payment arrangement entered into by Brace5 and the patient, Brace5 may suspend and stop performing the treatment.

12. TERMINATION OF TREATMENT

12.1 Brace5 may terminate this agreement and treatment immediately if the patient has:

(a) failed to pay any amount payable to Brace5 when due and payable has not paid such amount within 10 days of written demand by Brace5
(b) refused, neglected or repeatedly failed to comply with any request, direction or instruction of the Orthodontist or the Oral Health Therapist.
(c) Displayed, in the reasonable opinion of Orthodontist or Oral Health therapist, behaviour which is aggressive.
(d) Excessively broken or damaged orthodontic appliances provided to the patient pursuant to the treatment.
(e) Defame or disparaged Brace5 whether online or by word of mouth.
(f) commenced implementing treatment or advise of third party to detriment the treatment plan.
(g) breached a substantive provision of this agreement.

12.2 On the effective date of termination of the cessation of the treatment for any reason:

(a) The patient agrees to sign an early termination of treatment form and
(b) The fees and all other monies due and payable by the patient to Brace5 under this agreement become due and payable within 14 days.

12.3 Any termination of this agreement shall be without prejudice to any claim or accrued rights or remedies with either party may have form any cause arising prior to its termination.

13. FORMAL COMPLAINTS

13.1 If the patient is dissatisfied with any matters relating to the treatment, they agree to email [email protected] with details of the complaint.
13.2 If the event of a dispute the parties agree to use their best endeavours to resolve the dispute amicably through negotiations in good faith and other communications.
13.3 Upon the receipt of a complaint, Brace5 will provide a response within 30 days.
13.4 The parties agree that resolution of any dispute will be treated as urgent, and all parties will use their best endeavours to attend and provide information and generally give effect to the resolution of the dispute and will, wherever possible, avoid delay.

Risks and Limitations

RELAPSE

Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treatment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non- removable retainers or other dental appliances made by your family dentist.

ALLERGIES

Occasionally, patients can be allergic to some of the component materials of their orthodontic appliances. This may require a change in treatment plan or discontinuance of treatment prior to completion. Although very uncommon, medical management of dental material allergies may be necessary.

GENERAL HEALTH PROBLEMS

It is imperative that you inform your orthodontist of any medical conditions, changes, or medications in your general health status.

EXTRACTIONS

Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth which you should discuss with your treating dentist/practitioner prior to the procedure.

INTERPROXIMAL REDUCTION

During treatment, the patient may require teeth to be slenderized with IPR (interproximal reduction). This involves removing enamel from between the teeth slightly to reduce the widths for better form, function, and stability.
Occasionally the patient may feel some sensitivity to hot or cold.

ROOT RESORPTION

The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth through- out life with severely shortened roots. If resorption is detected during orthodontic treatment, your doctor may recommend a pause in treatment or the removal of the appliances prior to the completion of orthodontic treatment.

ATTACHMENTS

Attachments may be bonded to one or more teeth during the course of Invisalign® treatment to facilitate tooth movement and/or appliance retention. These will be removed after treatment is completed. Attachments may fall off and require replacement during treatment.

DENTAL CARIES AND DECALCIFICATION

Excellent oral hygiene is essential during orthodontic treatment as are regular maintenance visits to your dentist. Inadequate or improper hygiene could result in cavities, discoloured teeth, periodontal disease and/or decalcification. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened beverages or foods.

ORTHOGANATHIC SURGERY

Significant skeletal disharmonies require treatment in conjunction with orthognathic surgery. There are additional risks associated with this surgery which the patient should discuss with their surgeon prior to starting treatment. Please be away that treatment prior to orthognathic surgery often only aligns the teeth within the individual arches and patients who discontinue treatment without completing the planned surgical procedures may have malocclusion worse than at the beginning of the treatment.

PERIODONTAL DISEASE

Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. You must have your dentist and/or, if indicated, a periodontist monitors your periodontal health prior and during treatment every three to six months. If periodontal problems cannot be controlled the clear aligner treatment may not be a suitable option or may have to be discontinued prior to completion.

BLACK TRIANGLES

Teeth which have been overlapped for long periods of time may be missing the gingival tissue below the interproximal contact once the teeth are aligned, leading to the appearance of a “black triangle” space.

DENTAL RESTORATIONS

Existing dental restorations (e.g., crowns) may become dislodged and require re-cementation or in some instances, replacement.
A tooth that has been previously traumatized, or significantly restored may be aggravated by orthodontic forces, resulting in root or nerve complications needing other dental treatment.

OCCLUSAL ADJUSTMENT

You can expect minimal imperfections in the way your teeth meet following the end of treatment. An occlusal equilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion. It may also be necessary to remove a small amount of enamel in between the teeth, thereby “flattening” surfaces to reduce the possibility of a relapse.