Consent form
Clear aligner treatment
We've asked you to complete this before your appointment: read each section, fill in your details, then sign. It takes about five minutes, or about ten for Angel Align, which has its own consent form too.
More about this treatment: Clear aligners
Read each section
What it involves
Clear aligners are a series of removable, near-invisible plastic trays that move your teeth a little at a time. We use Invisalign or Angel Align, depending on your case.
Who is treating you. Your aligner treatment is provided by Dr Immanuel Puvanendiran, a general dentist with a special interest in clear aligners. He is not a registered specialist orthodontist. Complex cases, and cases better suited to specialist care, are referred to an orthodontist.
- Records. A digital scan of your teeth, photographs and X-rays. Aligners move teeth through bone, so the teeth, gums and bone need to be healthy first.
- The plan. Your treatment is planned on the aligner software, showing the intended movements and the number of aligners. The number varies from case to case, and you approve the plan before anything is made.
- Making space. Crowded teeth need somewhere to move into. Space is created either by slenderising — taking a very small amount of enamel from between the teeth, also called interproximal reduction or IPR — or, in some cases, by removing one or more teeth. We do both here. Which of these you need, if either, is part of the plan you approve before anything is made. Removing a tooth is a separate procedure with its own consent form and its own fee.
- The aligners. Worn 20 to 22 hours a day, removed only to eat, to drink anything other than water, and to clean your teeth. Changed every two weeks, or as instructed.
- Reviews every eight weeks, so we can check the teeth are tracking to plan. Review appointments are included in the treatment fee.
- Attachments, elastics and refinements. Small tooth-coloured buttons on some teeth, elastics, or a further series of aligners at the end are often needed to finish the movements properly.
Lost or damaged aligners may carry an extra charge.
Risks and possible complications
Like all orthodontic treatment, aligners carry risks. They include, but aren't limited to:
- Wear time. Not wearing the aligners as instructed is the most common reason treatment runs long or doesn't reach the planned result.
- Discomfort or pressure for a few days each time you change to a new aligner.
- Irritation of the gums, cheeks or lips, usually temporary.
- A lisp or altered speech at first, typically settling within one to two weeks.
- Decay, gum inflammation or white marks (decalcification) on the teeth if cleaning isn't kept up under the aligners.
- Root shortening (root resorption) — a minor shortening of the tooth roots can happen when any teeth are moved.
- Bite changes that need further adjustment or treatment.
- Black triangles. Teeth that have been crowded or overlapped for a long time are often narrower at the gum than they look, and the gum between them has had nothing to fill. Once they're straightened, small dark spaces can show near the gum line. This is a common and well-recognised result of straightening long-crowded teeth rather than a fault in the aligners, and it can't always be predicted before treatment begins.
- The shape of the teeth once they're straight. Aligners move teeth; they don't reshape them. When the teeth line up, worn edges, chips, uneven widths and black triangles often become more noticeable than they were before. Improving those means further treatment — slenderising, composite bonding, or in some cases crowns or veneers. That work is optional, it is quoted separately, and it is not part of the aligner fee.
- Movements that don't fully happen as planned, needing refinement aligners, attachments or elastics — or occasionally braces to finish.
- Relapse. Teeth drift back after treatment unless retainers are worn as prescribed.
- Allergic reaction to the aligner material — rare.
Results can't be guaranteed. How the teeth respond depends on wear time, on how you clean, and on biology that varies from person to person.
Your alternatives
- Traditional braces, which suit some movements that aligners manage less well.
- Other clear aligner systems.
- Referral to an orthodontist for complex cases.
- No treatment — accepting the current position of your teeth.
Attachments, stopping early, and refunds
Aligners are a customised treatment, made for your teeth alone. Once treatment has commenced — including once your aligners have been manufactured — no refund is available, including if you decide not to continue or not to complete treatment.
If you ask for the attachments to be taken off temporarily and put back later — for a wedding or photographs, say — a fee applies for the clinical time, materials and adjustments involved. The same fee applies if attachments are removed because treatment is stopped early. We'll tell you the amount before you decide.
Retainers afterwards
Teeth move back towards where they started unless they're held. Retainers are part of the treatment, not an optional extra: you'll be provided with a metal retainer and two sets of clear plastic retainers, and you'll need to wear them as instructed for as long as you want the teeth to stay where treatment put them.
How retainers are worn, repaired and replaced is set out on our retainers page, which you'll be asked to read when the aligners come off.
The fee, and health funds
Aligner treatment is charged as a single fee, quoted in writing at your consultation. It covers all consultations and reviews from the first assessment to the final check, the full course of aligners including any refinements, and your retainers. A payment plan through Denticare is available — Denticare fees apply.
Not included in that fee: removing any teeth needed to create space, and any work afterwards to improve the shape of the teeth — slenderising beyond what the plan calls for, composite bonding, crowns or veneers. Both are quoted separately, and you can ask for a written quote before deciding.
The fee doesn't take account of any rebate from your health fund. Cover for orthodontic treatment varies a lot between funds and policies, so contact your fund directly and ask about clear aligner orthodontic treatment, item number 825 (charged twice). Item numbers and policies change, so confirm with your own fund before starting.
Looking after it — your part
- Wear the aligners 20 to 22 hours a day and change them on schedule.
- Brush after eating before the aligners go back in, and clean between the teeth daily.
- Attend every eight-weekly review, and tell us promptly if an aligner is lost, cracked, or stops fitting.
- Wear your retainers as instructed once treatment finishes, and attend a check-up every 6 months, which isn't included in the treatment fee.
If you don't keep up the wear time, the cleaning or the appointments, treatment can run long, stall, or fail, and you would be liable for the full cost of correcting what follows.
Angel Align patients: Angelalign's consent form
If you're having Angel Align, Angelalign's own consent form is below, word for word, and you sign it with the same signature at the end. We keep their form, filled in and signed, on your file. Invisalign patients don't need this part.
Angelalign — about the treatment
Notice to treating office: This form is to be signed by your Angelalign® patients prior to treatment and kept for your records and should not be sent to Angelalign
PATIENT’S INFORMED CONSENT AND AGREEMENT REGARDING ANGELALIGN® ORTHODONTIC TREATMENT
Your doctor has recommended the Angelalign system for your orthodontic treatment. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment (including orthodontic treatment with Angelalign aligners) has limitations and potential risks that you should consider before undergoing treatment.
DEVICE DESCRIPTION
Angelalign aligners, developed by Angelalign consist of a series of clear plastic, removable appliances that move your teeth in small increments. Angelalign’s product combines your doctor’s diagnosis and prescription with sophisticated computer graphics technology to develop a treatment plan which specifies the desired movements of your teeth during the course of your treatment. Upon approval of a treatment plan developed by your doctor, a series of customised Angelalign aligners is produced specifically for your treatment.
PROCEDURE
You may undergo a routine orthodontic pre-treatment examination including radiographs (x-rays) and photographs. Your doctor will take impressions or intra-oral scans of your teeth and send them along with a prescription to the Angelalign laboratory. Angelalign technicians will follow your doctor’s prescription to create a IOrtho® software model of your prescribed treatment. Upon approval of the IOrtho treatment plan by your doctor, Angelalign will produce and ship a series of customised aligners to your doctor. The total number of aligners will vary depending on the complexity of your malocclusion and the doctor’s treatment plan. The aligners will be individually numbered and will be dispensed to you by your doctor with specific instructions for use. Unless otherwise instructed by your doctor, you should wear your aligners for approximately 20 to 22 hours per day, removing them only to eat, brush and floss. As directed by your doctor, you will switch to the next aligner in the series every two weeks or as directed by your doctor. Treatment duration varies depending on the complexity of your doctor’s prescription. Unless instructed otherwise, you should follow up with your doctor at a minimum of every 6 to 8 weeks. Some patients may require bonded aesthetic attachments and/or the use of elastics during treatment to facilitate specific orthodontic movements. Patients may require additional impressions or intra-oral scans and/or refinement aligners after the initial series of aligners.
BENEFITS
- Angelalign aligners offer an aesthetic treatment to conventional braces.
- Aligners are nearly invisible so many people will not realise you are in treatment.
- Treatment plans can be visualised through the iOrtho software.
- Aligners allow for normal brushing and flossing tasks that are generally difficult with conventional braces.
- The wearing of aligners may improve oral hygiene habits during treatment.
- Angelalign patients may notice improved periodontal (gum) health during treatment.
Angelalign — risks and inconveniences
RISKS AND INCONVENIENCES
Like other orthodontic treatments, the use of Angelalign product(s) may involve some of the risks outlined below:
(i) Failure to wear the appliances for the required number of hours per day, not using the product as directed by your doctor, missing appointments, and erupting or atypically shaped teeth can lengthen the treatment time and affect the ability to achieve the desired results;
(ii) Dental tenderness may be experienced after switching to the next aligner in the series;
(iii) Gums, cheeks and lips may be scratched or irritated;
(i) Teeth may shift position after treatment. Consistent wearing of retainers at the end of treatment should reduce this tendency;
(iv) Tooth decay, periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush and floss their teeth properly before wearing the Angelalign products, or do not use proper oral hygiene and preventative maintenance;
(v) The aligners may temporarily affect speech and may result in a lisp, although any speech impediment caused by the Angelalign® products should disappear within one or two weeks;
(vii) Aligners may cause a temporary increase in salivation or mouth dryness and certain medications can heighten this effect;
(viii) Attachments may be bonded to one or more teeth during the course of treatment to facilitate tooth movement and/or appliance retention. These will be removed after treatment is completed;
(ix) Attachments may fall off and require replacement;
(x) Teeth may require interproximal recontouring or slenderising in order to create space needed for dental alignment to occur;
(xi) The bite may change throughout the course of treatment and may result in temporary patient discomfort;
(xii) In rare instances, slight superficial surface wear of the aligner may occur where patients may be grinding their teeth or where the teeth may be rubbing and is generally not a problem as overall aligner integrity and strength remains intact;
(xiii) At the end of orthodontic treatment, the bite may require adjustment (“occlusal adjustment”);
(xiv) Atypically shaped, erupting and/or missing teeth may affect aligner adaptation and may affect the ability to achieve the desired results;
(xv) Treatment of severe open bite, severe overjet, mixed dentition, and/or skeletally narrow jaw may require supplemental treatment in addition to aligner treatment;
(xvi) Supplemental orthodontic treatment, including the use of bonded buttons, orthodontic elastics, auxiliary appliances/ dental devices (e.g. temporary anchorage devices, sectional fixed appliances), and/or restorative dental procedures may be needed for more complicated treatment plans where aligners alone may not be adequate to achieve the desired outcome;
(xvii) 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 theappearance of a “black triangle” space;
(xviii) Aligners are not effective in the movement of dental implants;
(xix) General medical conditions and use of medications can affect orthodontic treatment;
(xx) Health of the bone and gums which support the teeth may be impaired or aggravated;
(xxi) Oral surgery may be necessary to correct crowding or severe jaw imbalances that are present prior to wearing the Angelalign product. If oral surgery is required, risks associated with anesthesia and proper healing must be taken into account prior to treatment;
(xxii) A tooth that has been previously traumatised, or significantly restored may be aggravated. In rare instances the useful life of the tooth may be reduced, the tooth may require additional dental treatment such as endodontic and/ or additional restorative work and the tooth may be lost;
(xxiii) Existing dental restorations (e.g. crowns) may become dislodged and require re-cementation or in some instances, replacement;
(xxiv) Short clinical crowns can pose appliance retention issues and inhibit tooth movement;
(xxv) The length of the roots of the teeth may be shortened during orthodontic treatment and may become a threat to the useful life of teeth;
(xxvi) Product breakage is more likely in patients with severe crowding and/or multiple missing teeth;
(xxvii) Orthodontic appliances or parts thereof may be accidentally swallowed or aspirated;
(xxviii) In rare instances, problems may also occur in the jaw joint, causing joint pain, headaches or ear problems;
(xxix) Allergic reactions may occur;
(xxx) Teeth that are not at least partially covered by the aligner may undergo supraeruption;
(xxxi) In rare instances, patients with hereditary angioedema (HAE), a genetic disorder, may experience rapid local swelling of subcutaneous tissues including the larynx, HAE may be triggered by mild stimuli including dental procedures.
Angelalign — informed consent
INFORMED CONSENT
I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Angelalign aligners. I understand the benefits, risks, alternatives and inconveniences associated with treatment as well as the option of no treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment with Angelalign's product with my doctor from whom I intend to receive treatment.
I understand that I should only use the Angelalign product after consultation and prescription from an Angelalign trained doctor, and I hereby consent to orthodontic treatment with Angelalign’s product that have been prescribed by my doctor. Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor and Angelalign have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Angelalign is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give medical advice. No assurances or guarantees of any kind have been made to me by my doctor or Angelalign, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment.
I authorise my doctor to release my medical records, including, but not be limited to, radiographs (x-rays), reports, charts, medical history, photographs, findings, plaster models or impressions or intra-oral scans of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor’s possession (“Medical Records”) (i) to other licensed dentists or and organisations employing licensed dentists and orthodontists and to Angelalign, its representatives, employees, successors, assigns, and agents for the purposes of investigating and reviewing my medical history as it pertains to orthodontic treatment with product(s) from Angelalign and (ii) for educational and research purposes.
I understand that use of my Medical Records may result in disclosure of my “individually identifiable health information” as defined by the Health Insurance Portability and Accountability Act (“HIPAA”). I hereby consent to the disclosure(s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure. I acknowledge that use of my Medical Records is without compensation and that I will not nor shall anyone on my behalf have any right of approval, claim of compensation, or seek or obtain legal, equitable or monetary damages or remedies arising out of any use such that comply with the terms of this Consent.
A photostatic copy of this Consent shall be considered as effective and valid as an original. I have read, understand and agree to the terms set forth in this Consent as indicated by my signature below.
Your details
Full name
Date of birth
Mobile
Aligner system
Treating dentist
Total cost
Your acknowledgement
- I have been informed of the reasons for clear aligner treatment, the process, the risks, the alternatives and the maintenance needed during and after treatment.
- I understand my treatment is provided by a general dentist with a special interest in clear aligners, not by a registered specialist orthodontist, and that complex cases or cases better suited to specialist care are referred to an orthodontist.
- I understand the result depends on wearing the aligners 20 to 22 hours a day, changing them on schedule, keeping my teeth clean and attending my reviews.
- I understand space may need to be created for my teeth to move into, by slenderising a small amount of enamel between the teeth (interproximal reduction) or by removing one or more teeth, and that any removal is a separate procedure with its own consent and its own fee.
- I understand attachments, elastics or refinement aligners may be needed, and that treatment may take longer than first estimated.
- I understand the risks include discomfort, irritation, temporary speech changes, decay or gum problems if cleaning lapses, minor root shortening, and bite changes needing further treatment.
- I understand that black triangles — dark spaces near the gum — can appear once teeth that have been crowded or overlapped for a long time are straightened, and that this cannot always be predicted before treatment begins.
- I understand that further work such as slenderising, composite bonding, crowns or veneers may be wanted to improve the shape of my teeth once they are aligned, that this is optional, and that it is quoted separately and not included in the aligner fee.
- I understand no refund is available once treatment has commenced, including once my aligners have been manufactured.
- I understand a fee applies if I ask for attachments to be removed and replaced, or if they are removed because treatment is stopped early.
- I understand retainers must be worn as instructed after treatment, and that the teeth will move back if they are not.
- I understand there is no way to accurately predict how any individual's teeth will respond, and that orthodontic outcomes cannot be guaranteed.
- I agree to attend for regular examinations and cleans as instructed, and I understand that if I do not keep up maintenance I may be liable for the full cost of correcting problems that follow.
- I have given an accurate report of my physical and mental health and medical history, including any previous allergic or unusual reactions to drugs, foods, anaesthetics, or any abnormal bleeding.
- I understand that no guarantee or assurance has been given that treatment will be completely successful in function or appearance, and that dentistry is not an exact science.
- I have read the information above and had the chance to ask questions.
- The costs have been explained to me, and I can ask for a written quote before treatment starts.
Acknowledgement wording ref 34a1464b
Signature
Date
Parent or guardian name and signature, if the patient is under 18
This form records that you have read and understood the information above. It is not consent to proceed — your dentist confirms consent with you in person before treatment begins, and you can withdraw at any time.