Consent Forms

Please note, it is important that the forms are completed the day before your appointment.

Your Details
Name*
Prefix First Last
Email*
To receive a copy of this form please enter your email
Enter Email Confirm Email
DOB*
This field is hidden when viewing the form
Treating Dentist Name
This field is hidden when viewing the form
Consent Form Type*
- Denture Consent
- Tooth Whitening Consent
- Crown Consent
- Extraction Consent
- Radiography Consent
- Root Canal Patient Consent
- Periodontal treatment consent
- Direct Access Periodontal treatment consent
- Inman Aligner
- Six Month Smile Patient Agreement
- iTero informed consent
- Invisalign informed consent
- Direct access hygienist consent
- Intravenous Sedation consent
- Emergency Appointment Consent for Non-Registered Patients
- SmileFast Direct - Patient Consent Form
- Patient Smile Evaluation
Denture Consent
Constructing a denture is a dental procedure a removable prosthesis is a custom made for the mouth to replace one or more missing teeth. The intended benefits of the procedure include cosmetic and functional improvements for the mouth.
As with all medical procedures, there are risks and potential complications that you must be aware of before you can give your consent to proceed.
Expected complications*
- Select All
- Dentures are by definition a removable prosthesis and therefore do not work like natural teeth.
- They must be removed for cleaning and kept out of the mouth at night.
- Most people find that dentures can sometimes move or become dislodged.
- Requirement for adjustments, relining or remaking of the denture in the future.
Common risks and complications*
- Select All
- Dentures may rub on the gums and cause ulcers.
- Some dentures put additional stress on remaining teeth, fillings, or crowns resulting in additional work being required in the future.
- Dentures can be broken or lost resulting in inconvenience whilst they are sent away being repaired or remade.
Rare risks and complications*
- Allergic reaction to something used during the procedure.
Dentures are not successful 100% of the time even if all parts of the procedure go as planned. Some people struggle with dentures even if they are technically excellent and may then wish to replace the missing teeth in a different way.
Alternative options*
- Select All
- 1.Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment etc.
- 2. Replacing the teeth in a different way such as a bridge or implant.
- 3. Refusing treatment but this will result in the situation remaining as it is.
Please Read and Tick*
By signing below I acknowledge that this procedure has been explained to me and I have had time to ask questions, consider my options, and am happy to proceed. I am also aware that I have the right to seek a second opinion from another dentist at any time.*
Signature*
Date of Signature
Periodontal treatment consent
Periodontal treatment is a dental procedure during which the teeth are cleaned above and below the gums. The intended benefits of the procedure include the elimination of active periodontal disease (also called gum disease) aiming to prevent the loss of teeth.
As with all medical procedures, there are risks and potential complications that you must be aware of before you can give your consent to proceed.
Expected complications*
- Select All
- Numbness lasting a few hours.
- Soreness of the gums lasting a few days.
- Requirement for maintenance cleaning in the future.
Common risks and complications*
- Select All
- Trauma to other parts of the mouth including teeth, gums, cheeks, tongue, etc.
- Some teeth will have increased sensitivity for some time after the procedure.
- Inability to clean the tooth well enough to control periodontal disease.
- Cosmetic changes to the gums.
Rare risks and complications*
- Select All
- Trauma to tissues underneath the tooth including bone, sinus, nerves supplying other teeth, etc.
- Allergic reaction to something used during the procedure.
Periodontal treatment is not successful 100% 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 might require extraction.
Alternative options*
- Select All
- 1. Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment etc.
- 2. Treating the tooth in a different way such as extraction.
- 3. Refusing treatment but this will result in a high risk of further loss of gum strength ultimately leading to loss of some teeth.
Signature*
Date of Signature
Tooth Whitening Consent
Tooth whitening is a dental procedure during which a peroxide solution is used to permanently change the colour of the teeth. The intended benefits of the procedure include returning the teeth back to the shade they may have been in youth or sometimes even lighter.
As with all medical procedures there are risks and potential complications which you must be aware of before you can give your consent to proceed.
This is a non-refundable treatment
Expected complications*
- Select All
- Most people experience some increased sensitivity to cold stimuli while undergoing this process.
- Your teeth will continue to naturally age and darken following this procedure, you may wish to top up in the future.
Common risks and complications*
- Select All
- The extent to which your teeth will whiten cannot always be accurately predicted. The effect can be greater for some people than others.
- Only tooth material will whiten so some fillings and crowns may look out of place afterwards,, you may wish to top up in the future.
Rare risks and complications*
- Allergic reaction to something used during the procedure.
*
By signing below I acknowledge that this procedure has been explained to me and I have had time to ask questions, consider my options and am happy to proceed. I am also aware that I have the right to seek a second opinion from another dentist at any time.*
Signature*
Date of Signature
Crown Consent
Placing a crown is a dental procedure during which the tooth is shaped and a lab-made restoration is custom made and fitted to the tooth. The intended benefits of the procedure include returning the tooth to its correct shape and good strength.
As with all medical procedures, there are risks and potential complications that you must be aware of before you can give your consent to proceed.
Expected complications*
- Select All
- Numbness lasting a few hours.
- Soreness of the gums lasting a few days.
Consent*
Please tick to confirm the information is correct & Sign below*
Common risks and complications*
- Select All
- Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue, etc.
- Some teeth will still be sensitive for some time after the procedure.
- Darkening of the root of the tooth depending on the material used.
- Inability to return the tooth to a perfect shape which could result in it being more difficult to look after.
- A small risk of loss of vitality (nerve dying) and the need for root canal treatment (RCT) following placement of crown
Consent*
Please tick to confirm the information is correct & Sign below*
Rare risks and complications*
- Select All
- Removing tooth material to make space for the crown can irritate the nerve inside the tooth sometimes leading to the nerve dying and causing a toothache.
- Trauma to tissues underneath the tooth including bone, sinus, nerves supplying other teeth, etc.
- Allergic reaction to something used during the procedure.
Consent*
Please tick to confirm the information is correct & Sign below*
Crowns are not successful 100% of the time even if all parts of the procedure go as planned. The tooth may not have enough strength left prior to this procedure for a long-term result. Decay and 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 a root canal treatment or might require extraction.
Alternative options*
- Select All
- 1. Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment etc.
- 2. Treating the tooth in a different way such as extraction.
- 3. Refusing treatment but this will result in a high risk of fracture or pain and infection from this tooth.
Signature*
Date of Signature
Extraction Consent
Extraction is a dental procedure during which a tooth is removed normally because it has a major problem and has not got a good long term prognosis. The intended benefits of the procedure include the removal of pain and/or infection or aiming to make the mouth less prone to future problems.
As with all medical procedures, there are risks and potential complications that you must be aware of before you can give your consent to proceed.
Expected complications*
- Select All
- Numbness lasting a few hours.
- Soreness, bruising, and localised swelling lasting up to a week.
Common risks and complications*
- Select All
- Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue, etc.
- Prolonged post-operative pain due to poor healing or infection.
- Fracture of the tooth during the procedure which can lead to a minor surgical procedure being required or a piece of the tooth being left because it cannot be removed.
Rare risks and complications*
- Select All
- Trauma to tissues underneath the tooth including bone, sinus, nerves supplying other teeth, etc.
- A communication (hole) between the mouth and sinus.
- Displacement of part of the tooth into the sinus.
- Allergic reaction to something used during the procedure.
Alternative options*
- Select All
- 1.Referral to a specialist in this field who may be able to treat the tooth better via the use of specialist equipment etc.
- 2. It may be possible to save the tooth with different treatment such as root canal treatment etc.
- 3. Refusing treatment but this will result in a high risk of further pain and infection from this tooth.
Signature*
Date of Signature
Radiography Consent
Your Dentist may advise that it would be beneficial for you to have some Dental X-Rays taken as part of your Examination.
These X-rays will help your dentist to diagnose and prevent oral health issues.
Using X-Rays your Dentist can:*
- Select All
- Identify cavities in teeth
- Look at the roots of the teeth for signs of infection or abnormalities.
- Check the health of the bone around the teeth
- Identify tooth decay under existing fillings, crowns and bridges
- Evaluate implants and Root Canal Treatments
When X-Rays are taken, some of the radiation produced is absorbed into the body. This is called the “radiation dose”.
The radiation dose from one Dental X-ray is equivalent to: • 1.5 days of naturally occurring background radiation • A two-hour flight • Eating 145g of Brazil Nuts
The Radiation dose generated at The Dental Touch is subject to national regulations. All of our equipment is maintained and the settings are tested routinely for accuracy.
If you have any concerns about having an X-Ray, please speak with your Dentist so that they can address them with you
Consent*
I give consent for X-rays to be taken:*
Signature*
Name*
Date of Signature
Root Canal Patient Consent
Root canal treatment (RCT) is a dental procedure during which the nerve is removed from a tooth normally because the nerve is dying or has died. The intended benefits of the procedure include removal of pain and/or infection at the base of the tooth.
As with all medical procedures, there are risks and potential complications that you must be aware of before you can give your consent to proceed.
Expected complications*
- Select All
- Numbness lasting a few hours.
- Soreness of the gums lasting a few days.
Common risks and complications*
- Select All
- Trauma to other parts of the mouth including adjacent teeth, gums, cheeks, tongue, etc.
- The weakening of the tooth being treated meaning it might require further work in the future to restore it to decent strength.
- Darkening of the tooth.
- Inability to locate, clean, and seal all parts of the root canal resulting in failure to remove all pain and/or infection.
Rare risks and complications*
- Select All
- Fracture of the tooth resulting in extraction being required.
- Separation (fracture) of an instrument within the tooth.
- Perforation of the floor or root of the tooth by an instrument.
- Trauma to tissues underneath the tooth including bone, sinus, nerves supplying other teeth, etc.
- Allergic reaction to something used during the procedure.
Root canal treatment is not successful 100% of the time even if all parts of the procedure go as planned. Therefore some teeth that have undergone this procedure will require the RCT to be re-done or might require extraction.
Alternative options*
- Select All
- 1. Referral to a specialist in this field who may be able to treat the tooth better via the use of a microscope and specialist equipment etc.
- 2. Extraction leading to a gap or further work to replace the tooth such as a bridge, implant, or denture.
- 3. Refusing treatment but this will result in a high risk of further pain and infection from this tooth.
Unfortunately, if treatment is not completed due to certain clinical complications, the treatment fee will still be applicable
Signature*
Date of Signature
Inman Aligner
The following information is routinely supplied to anyone considering treatment with the Inman Aligner. While recognising the benefits of a pleasing smile and healthy teeth, you should also be aware that Inman Aligner treatment, like any treatment of the body, has some inherent risks and limitations. These are seldom enough to contra-indicate treatment, but should be considered in making a decision to start treatment.
Please feel free to ask any questions before, during and after the treatment.
- It is your responsibility to follow the brushing and oral hygiene instructions that are given to you, to help prevent harm to the teeth and surrounding tissues.
- You must come to all appointments on the proper day and time.
- You must not eat whilst wearing the Inman Aligner, in order to keep from damaging the teeth, the Inman Aligner and retainers. This will enable the treatment time will be as short as possible and us to achieve the best results.
- You must visit a dentist at least every 6 months for an examination and cleaning.
- Please be aware that there will be additional charges for replacement of appliances (such as retainers or braces) that are lost or damaged due to repeated patient neglect, or any excessive extension of treatment due to lack of patient co-operation. 100% patient co-operation is very important.
Oral hygiene: Decalcification (permanent markings), decay, or gum disease can occur if patients do not brush their teeth properly and thoroughly during treatment period. Although this is much less prevalent with removable orthodontics like the Inman Aligner, excellent oral hygiene and plaque removal is a must.
Sugars and between meal snacks should be reduced as much as possible.
A non-vital or dead tooth is a possibility:  A tooth that has been traumatized from a deep filling or even a minor blow can die over a period of time with or without orthodontic treatment. An undetected non-vital tooth may flare up during movement, requiring endodontic (root canal) treatment to maintain it.
Root resorption:  In some cases, the root ends of the teeth are shortened during treatment. This is called root resorption. Under healthy circumstances the shortened roots are no disadvantage. However, in the event of gum disease in later life the root resorption may reduce the longevity of the affected teeth. It should be noted that not all root resorption arises from orthodontic treatment. Trauma, cuts, impaction, endocrine disorders, unknown causes can also cause root resorption.
Growth issues: Occasionally a person who has grown normally and in average proportions may not continue to do so. If growth becomes disproportionate, the jaw relation can be affected and original treatment objectives may have been compromised. Skeletal growth disharmony is biologic process beyond the dentists control. Some patients will require oral surgery to obtain a reasonable treatment result to complete their case. Most patients we can inform ahead of time prior to starting any treatment that is necessary and you will be referred to an orthodontist for comprehensive orthodontic.
Gum tissues: The bone-gum relationship around teeth is always dependent upon whether there is enough bone to support the gum tissue properly. Many times when very crowded teeth are straightened there is a lack of bone and supporting gum tissues surrounding the teeth. Therefore, the gum tissue contour and support may not be adequate and require periodontal intervention.
Treatment time:  The total time for treatment can be delayed beyond our estimate. Lack of co-operation, broken appliances and missed appointments are all important factors that could lengthen treatment time and effect the quality of the result.
TMJ: There is a risk that problems may occur in the temporomandibular joints (jaw joints). Although this is rare, it is a possibly.   Tooth alignment or bite correction sometimes can improve tooth related causes of TMJ pain, but this is not in all cases. Tension appears to play a role in the frequency and severity of joint pains, and there are many other causes of TMJ dysfunction.
Very unusual occurrences: Swallowed appliances, chipped teeth, dislodged restorations and allergies to latex or nickel rarely occur but are possible.
Termination of treatment: It is understood that treatment can be terminated for failure to cooperate, missing appointments, not wearing appliances, excessive breakage, failure to keep financial commitments, relocation, personal conflicts or for any other reason the dentist feels necessary. If termination is necessary, the patient will be given ample time to locate another dentist to continue treatment.
Expectations: All patients can expect improvement with their particular problem, but in many case, absolute perfection is impossible due to lack of muscle balance, tooth shapes and sizes and varying degrees of co-operation during treatment, along with heredity aspects that affects everyone’s specific treatment results.
Relapse: Teeth have a tendency to return to their original position after orthodontic treatment. This is called relapse. Very severe problems have a higher tendency to relapse and the most common area for relapse is the lower front teeth. After removal, a positioner or retainers are place to minimise relapse. Full co-operation in wearing these appliances is vital. We will make our correction to the highest standards and in many case over correct in order to accommodate the rebound tendencies. When retention is discontinued relapse is highly likely.
Consent*
Records: I consent to the taking of photographs, study models and x-rays before, during and after orthodontic treatment to assist in the planning and progress treatment objectives. I confirm that I have read or had read to me the contents of this form and do realise the risks and limitations involved, and consent to Inman Aligner treatment.*
Consent*
Consent: I understand the treatment with an Inman Aligner may be compromise and not fully comprehensive orthodontics. I certify that my dentist has offered me the option to see an orthodontist to have fully comprehensive orthodontic treatment.*
Signature*
Date of Signature
Six Month Smile Patient Agreement
This Patient Agreement contains important information about your treatment. BY SIGNING THIS PATIENT AGREEMENT, YOU ACKNOWLEDGE THAT YOU HAVE READ AND AGREE TO ALL OF THE TERMS AND CONDITIONS CONTAINED HEREIN. Please read carefully and ask questions about any areas that are unclear:
Scope of Treatment: Our objective is to straighten your teeth, usually without significant bite change, in a reasonable time frame-usually 4-9 months. You may have aspects of your bite that will not be addressed with this treatment, such as, but not limited to, molar relationships/posterior cross bite, overjet, underjet, facial profile, TMJ problems, displaced tooth roots and midline discrepancies. Full correction of the items mentioned here can oftentimes involve years of orthodontic treatment. The goal of this cosmetically focused and short-term orthodontic treatment is to correct your chief cosmetic complaints, which you have shared with us. This treatment is not a replacement for traditional comprehensive orthodontic treatment. This cosmetically focused treatment is an alternative for people who are not interested in traditional comprehensive orthodontic treatment and are seeking a more cosmetically focused orthodontic treatment option that can be provided over a shorter period of time.
Hygiene: BRUSH YOUR TEETH, GUMS, braces and wires thoroughly after each meal and before going to bed. Poor oral hygiene can result in puffy, bleeding gums and permanent white spots on teeth. INFLAMMATION AND BLEEDING GUMS WILL DELAY YOUR TREATMENT. An interproximal brush is the best way to clean around your braces and can be purchased in any grocery store/pharmacy. Use this brush between your teeth at the gumline. We do reserve the right to suspend or delay treatment if your oral hygiene is poor. Keep your teeth and braces clean!
Hard Food: DO NOT EAT hard food such as popcorn, ice, toffees or hard sweets. These foods can break the brackets. CUT UP foods such as meats, apples, carrots etc. before eating them.
Soreness: After the braces are put on the teeth may be sore, usually for 2-4 weeks. Aspirin, Advil or Aleve may be taken to relieve this. If the soreness prohibits eating even soft food, please phone for an appointment so any necessary adjustments may be made. If the inside of the lips are sore, the wax that is provided can be used as a cushion over the braces until the lips become accustomed. Taking pain medication prior to your adjustment appointments can help minimize discomfort.
Jaw Joint: There are some patients who will develop a popping/clicking or other problems in their jaw joint during or after orthodontic treatment. This is very rare. Usually, orthodontic treatment provides a positive effect on the jaw joint. You should understand that pre-existing joint conditions can manifest as a popping or clicking after orthodontic treatment but orthodontic treatment by itself has not been shown to cause popping/clicking of the jaw joints.
Main Objective: I understand that the main objective of my orthodontic treatment is to align my teeth for cosmetic reasons. My bite and the relationship of my back teeth are not the focus of this treatment. 3-6 months may be required after treatment for the bite to settle and be completely comfortable. Significant changes in lip profile necessitate jaw surgery, which I am not seeking. I am aware of these objectives and limitations of short-term treatment. I fully understand that my course of treatment may not result in complete orthodontic correction. This is not mainstream orthodontic treatment philosophy and many orthodontists will disagree with this type of orthodontic treatment that does not aim to completely correct/change the bite relationship.
A Cephalometric X-ray will not be taken: A cephalometric x-ray is usually taken in association with traditional comprehensive orthodontics. This type of x-ray shows the relationship of the skull, skeleton and teeth. This type of x-ray does not provide us with essential information for performing cosmetic tooth alignment. Therefore, a cephalometric x-ray is not typically taken in association with cosmetic tooth alignment. By signing this consent form, you are communicating that you understand that this type of x-ray will not be part of your pre-treatment records. If you desire more information about this topic, please ask the doctor.
Technique: Space will be made by enamel reproximation (minor tooth reduction). This allows limited tooth movement in the area of the crowding. Rarely sensitivity is possible from this, but is transient and not common. Alternative treatment options to enamel reproximation for making space include tooth extraction, which we only perform in extreme cases of crowding, and expanding the dental arch is proven to be unstable in adult patients. Upper and lower dental midlines will not be made to coincide for most cases as midline changes often require years of treatment. Misshaped and abnormally long teeth will be reshaped as part of treatment. On occasion, bonding may be needed to provide an even appearance of the edges of front teeth whether because of stubborn tooth movement or misshaped teeth. Charges for bonding will be determined on a case-by-case basis.
Standard of Straightness: We seek to straighten teeth to a very high level with cosmetically focused orthodontic treatment. If, however, numerous custom requests arise which the doctor feels will take an inordinate amount of extra time or in fact may not even be possible to achieve, we reserve the right to refer you to an orthodontic specialist for conventional comprehensive, 2 year, bite-changing orthodontic treatment, without a refund of monies paid up until that point in treatment.
Retention: Teeth have a tendency to rebound to their original positions after orthodontic treatment. Very severe problems have a higher tendency to relapse, and the most common type of relapse occurs with twisted teeth. Retainers will be placed immediately to minimize relapse. Full cooperation in wearing these appliances (full time for 6 months, at night for 6 months, and every other night indefinitely) is essential and part time wear is required for years. There is a fee to replace lost retainers. There are both fixed and removable options for orthodontic retainers.
Cleanings: You should have at least one professional cleaning during your treatment. If you have an appointment for a cleaning scheduled, keep it! This is not required but highly encouraged.
Appointments: Please keep your adjustment appointments! Missed appointments can result in delayed completion. Please notify us at least 48 hours in advance should you need to reschedule since another patient may need this time slot. There can be a fee assessed for all broken appointments or short notice cancels. There are some visits that are required after your braces are off (retainer checks etc.). These visits are very important. Relapse, bite settling, and retainer or splint adjustments (or breakage) are just some of the items we wish to monitor in this stage.
Moving: If you plan on moving during orthodontic treatment, it is usually advisable to complete treatment with our office. It would be difficult to change doctors during treatment.
Disclaimer and Release of Liability: I understand that the dentist who is providing my cosmetic tooth alignment is a general dentist, is not an orthodontist, and is not employed by, an agent of, affiliated with, or licensed by Six Month Smiles, LLC. Six Month Smiles provider status denotes only that a dental professional has completed the training course offered by Six Month Smiles, LLC. that is necessary to enable him or her to begin treating patients with the Six Month Smiles system. I understand that the certificate provided by Six Month Smiles, LLC. to my dentist attests only to my dentist’s attendance at, and completion of, the Six Month Smiles training course and does not attest to, certify, or guarantee any level of skill or expertise or any quality of performance. I understand and acknowledge that Six Month Smiles, LLC. makes no warranties or representations regarding, and does not guarantee or certify the quality of, the services provided by my dentist or any other licensed health care professional.
Consent*
I HAVE READ THIS PATIENT AGREEMENT AND FULLY UNDERSTAND ITS TERMS.*
Signature*
Date of Signature
iTero informed consent
Patient’s informed consent and agreement regarding iTero® intraoral scan
Your doctor has recommended the use of an iTero intraoral scan as part of your dental and/or orthodontic treatment. This involves your doctor capturing a 3D image of your teeth and mouth for various purposes, as determined by your doctor. The
use of the iTero scanner requires that your doctor pass your personal data, including sensitive health data, to Align Technology, Inc. headquartered in San Jose, California (“Align”) for the purposes of processing your personal data to provide services to your doctor at his or her request.
Informed Consent
I have been informed by my doctor of the nature of the procedure and I understand the benefits, risks, and alternatives for an iTero intraoral scan. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about my dental and/or orthodontic treatment with my doctor from whom I intend to receive treatment. I hereby consent to my doctor’s use of the iTero intraoral scanner as part of my dental and/or orthodontic treatment.
Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor and Align have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Align 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 Align, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment. I understand and consent to my doctor collecting and using my medical records, including, but not limited to, radiographs (x-rays), reports, charts, medical history, photographs, findings, plaster models, impressions of teeth, or intra-oral scans, prescriptions, diagnosis, medical testing, test results, ethnicity, billing, and other treatment records in my doctor’s possession (“Medical Records”) to the extent necessary for treatment, customer service, and billing. If I do not provide my consent to these uses of my Medical Records then I may not be able to receive an iTero intraoral scan.

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 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.
Privacy Notice
Your doctor is the controller of any personal data included in your Medical Records. Align and other members of its corporate group ("Align Group") will receive your medical records, which may be stored on Align Group's servers outside your country of residence. However, the Align Group will continue to protect your information in accordance with the Align Group's Binding Corporate Rules (“BCRs”), which can be found at www.aligntech.com.
Your Medical Records will only be shared with other third parties if otherwise permitted by the applicable law, such as if necessary to protect your vital interests or those of another person or if necessary for the establishment, exercise or defence of legal claims. Your doctor and the Align Group will process your Medical Records for the purpose of your treatment. The Align Group may also anonymise your Medical Records and use it for internal, analysis and research purposes. Your doctor and the Align Group will retain your Medical Records for only as long as it has an ongoing legitimate need to do so, for example, to provide you with treatment and to comply with regulatory obligations. The Medical Records will then be either deleted or anonymised or if this is not possible (for example, because your Medical Records have been stored in
backup archives), then they will be securely stored until deletion is possible.
If you have any questions about how your Medical Records are being used you can ask your doctor, including about any of your rights to:
- access, correct, update or request deletion of your Medical Records;
- restrict processing of your Medical Records;
- request that your doctor transfer your Medical Records to another doctor; and
- withdraw your consent at any time to the processing of your Medical Records. You also have the right to complain to your local data protection authority about the collection and use of your Medical Records.
Signature*
Date of Signature
Invisalign informed consent
Your doctor has recommended the Invisalign 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 Invisalign aligners) has limitations and potential risks that you should consider before undergoing treatment.
Device Description
Invisalign aligners, developed by Align Technology, Inc. (“Align”) consist of a series of clear plastic, removable appliances that move your teeth in small increments. Invisalign’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 Invisalign 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 intraoral scans of your teeth and send them along with a prescription to the Align laboratory. Align technicians will follow your doctor’s prescription to create a ClinCheck® software model of your prescribed
treatment. Upon approval of the ClinCheck treatment plan by your doctor, Align 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
- Invisalign aligners offer an aesthetic alternative to conventional braces.
- Aligners are nearly invisible so many people won’t realise you are in treatment.
- Treatment plans can be visualised through the ClinCheck software.
- Aligners allow for normal brushing and flossing tasks that are generally impaired by conventional braces.
- Aligners do not have the metal wires or brackets associated with conventional braces.
- The wearing of aligners may improve oral hygiene habits during treatment.
- Invisalign patients may notice improved periodontal (gum) health during treatment.
Risks and Inconveniences
- Like other orthodontic treatments, the use of Invisalign 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;
- (iv) Teeth may shift position after treatment. The consistent wearing of retainers at the end of treatment should reduce this tendency;
- (v) 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 Invisalign products, or do not use proper oral hygiene and preventative maintenance;
- (vi) The aligners may temporarily affect speech and may result in a lisp, although any speech impediment caused by the Invisalign® 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 are tooth-coloured “buttons” that may be bonded to one or more teeth during the course of treatment to facilitate tooth movement and/or appliance retention. Use of attachments may make it more noticeable that you are in treatment. 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 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 remain 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 the appearance 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 Invisalign 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.
Informed Consent
I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Invisalign 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 Invisalign® products with my doctor from whom I intend to receive treatment. I understand that I should only use the Invisalign products after consultation and prescription from an Invisalign trained doctor, and I hereby consent to orthodontic treatment with Invisalign products that have been prescribed by my doctor.
Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor and Align Technology, Inc. headquartered in San Jose, California (“Align”) have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Align 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 Align, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment.
I understand and consent to my doctor collecting and using my medical records, including, but not limited to, radiographs (x rays), reports, charts, medical history, photographs, findings, plaster models, impressions of teeth, or intra-oral scans, prescriptions, diagnosis, medical testing, test results, ethnicity, billing, and other treatment records in my doctor’s possession (“Medical Records”) to the extent necessary for treatment, customer service, and billing. If I do not provide my consent to these uses of my Medical Records then I may not be able to receive Invisalign treatment.
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 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.
Privacy Notice
Your doctor is the controller of any personal data included in your Medical Records. Align and other members of its corporate group ("Align Group") will receive your medical records, which may be stored on Align Group's servers outside your country of residence. However, the Align Group will continue to protect your information in accordance with the Align Group's Binding Corporate Rules (“BCRs”), which can be found at www.aligntech.com.
Your Medical Records will only be shared with other third parties if otherwise permitted by the applicable law, such as if necessary to protect your vital interests or those of another person or if necessary for the establishment, exercise or defence of legal claims. Your doctor and the Align Group will process your Medical Records for the purpose of your treatment. The Align Group may also anonymise your Medical Records and use it for internal, analysis and research purposes. Your doctor and the Align Group will retain your Medical Records for only as long as it has an ongoing legitimate need to do so, for example, to provide you with treatment and to comply with regulatory obligations. The Medical Records will then be either deleted or anonymised or, if this is not possible (for example, because your Medical Records have been stored in backup archives), then they will be securely stored until deletion is possible.
If you have any questions about how your Medical Records are being used you can ask your doctor, including about any of your rights to:
- access, correct, update or request deletion of your Medical Records;
- restrict processing of your Medical Records;
- request that your doctor transfer your Medical Records to another doctor; and
- withdraw your consent at any time to the processing of
- your Medical Records.
- You also have the right to complain to your local data protection authority about the collection and use of your Medical Records
Signature*
Date of Signature
Direct Access Hygienist Consent
Background
The General Dental Council permits patients to directly access the services of dental hygienists from 1 May 2013. Previously, a dentist had to see a patient prior to prescribing hygiene treatment. This meant that you would have been examined to see whether you had oral problems that warranted further treatment or investigation.
Direct Access
You need to understand the scope of what a dental hygienist does and can't do. A hygienist can see you to provide oral hygiene advice, remove stain, tartar, bacterial deposits, and other debris. In relation to gums, the hygienist can advise you on the progression of gum disease, but more advanced conditions need to be assessed by a dentist, and the hygienist then continues treatment under the prescription of the dentist.
Dental hygienists can't diagnose or give the prognosis (the likely outcome) of diseases such as decaying and broken teeth, or prescribe antibiotics, painkillers or any other drugs to alleviate symptoms.
Visits to hygienists is not a substitute for full dental examinations.
Referral to dentist
If the hygienist advises you to see a dentist, it is because they feel that it is in the interests of your health, it is outside the scope of what they are allowed to do, or they are uncertain about treating you without further advice.
There are very rare circumstances when a hygienist can't start treatment, and before they are prepared to continue, insist that a dentist assesses you. These may relate to your medical history and general health, or the condition of your mouth, which gives them concern.
Consent
I have read and understand the limitations of direct access to a dental hygienist and agree to be treated under the direct access arrangements. I understand that the hygienist is not responsible for the overall health of my mouth and that regular visits to a dentist are still required.
Signature*
Date of Signature
Direct Access Periodontal Treatment Consent
Signature*
Date of Signature
Intravenous Sedation Consent
What is Intravenous Sedation?
- Intravenous sedation is used to help relax you during minor surgical procedures.
- The sedative is given by injection into a vein (intravenous) in your arm or the back of your hand.
- You will remain conscious at all times and able to talk and respond to instructions.
- You will also receive local anaesthetic (an injection into your gums) so that the treatment can be carried out.
- Afterwards you will probably have little or no memory of the procedure.
Risks
As with any procedure, there are some possible risks and side effects associated with Intravenous Sedation. These include:
1. Bruising or tenderness of the veins or vessels into which the medications are placed.
2. Depressed respirations.
If you are having intravenous sedation there are some rules that you must follow for your safety:
- A responsible adult (friend or relative) must stay at the practice during your treatment and drive you home afterwards; if not, you cannot have sedation.
- Remember, to tell Dr Bohra before your treatment of any changes in your medical history, your medication and if you have asthma or any allergies.
On the day of your treatment
1. Report any recent changes in health or any onset of symptoms of sickness, especially fever or respiratory illness such as colds or flu like symptoms.
2. Take prescribed medications with a sip of water unless previously instructed otherwise.
3. Wear loose, comfortable clothing.
4. Remove all jewellery and leave at home.
5. A responsible adult (18 years or older) must accompany you, and be accessible at the practice and available to drive you home.
6. Failure to comply with these instructions may result in cancellation of surgery.
7. Do not drink any alcohol.
8. Treatment and recovery time is usually1-1/2 hours.
9. Please do not wear make-up on the day of your surgery.
After your treatment under sedation
- A responsible adult must drive you home and stay with you for at least 6 hours following the treatment. You must not travel home by public transport such as a bus.
- You should stay at home resting quietly for about 12 hours.
- Do not drive a car, drink alcohol, use machinery (such as a kettle or a bike), do any work or make important decisions for 12 hours, to allow the effects of the sedation to wear off.
- You can eat and drink normally as soon as you feel like it.
- If you have any pain then do not hesitate to take the painkillers as directed.
- If you consent to treatment under IV Sedation, please sign & print below:
Signature*
Date of Signature
Emergency Appointment Consent for Non-Registered Patients
Welcome to Dental Touch and thank you for booking an appointment with us.

The emergency appointment which has been made for you is intended only to provide a temporary solution to the dental issue you have sought our help for. We will do what we can to provide a short-term solution for the issue including giving pain relief where appropriate, extra charges may occur from explanation from the dentist where treatment is received during the appointment but the appointment will not cover permanent treatment solutions, for example tooth extractions, permanent crowns or permanent fillings.

If any further treatment is required to rectify the issue or to find a more permanent solution, we will usually advise you to book a New Patient Examination with a dentist (which carries a fee of £90). The purpose of this appointment will be to plan any further treatment required to make you dentally fit following your emergency appointment; any such treatment would be carried out at a later date.

The only medication included in the price of this appointment is Amoxicillin. If any further medications are prescribed, there may be a fee for these.

By signing this form, you are agreeing to the conditions stated above.
Signature*
Date
MM slash DD slash YYYY
SmileFast Direct - Patient Consent Form
Please read this form carefully and discuss with your dentist any points which require further clarification:
What is SmileFast Direct
SmileFast Direct is a sophisticated technique using the latest digital technology to design and test your perfect smile and to provide high quality composite bonding. This offers a solution to improve the appearance of your teeth by closing gaps, fixing worn/chipped teeth and improving teeth colour and shape.
Composite is bonded to the teeth, usually without any significant drilling or damage to your tooth- the colour is matched to your teeth to give a seamless join and mimicking the real tooth.
Composite bonding can help you achieve a smile you are happier with, with minimal time and minimal damage to your natural teeth.
The alternatives are Ceramic Crowns or Veneers which require your natural teeth to be prepared (shape adjusted).
Limitations
The SmileFast Direct system has been designed to improve the appearance of your teeth using composite restorative material. There are several situations which are out with the scope of this type of treatment.
These include but are not limited to:
1. The oral hygiene is not acceptable to receive any form of ‘cosmetic’ dental restoration (too much plaque/not brushing/flossing enough).
2. The general deterioration and health of the teeth has progressed beyond the capabilities of what constitutes cosmetic treatment only. We recommend that dental health is completely fixed before any cosmetic treatment.
3. The colour/staining of the teeth will not be sufficiently masked by composite material and may compromise final aesthetic outcome.
4. The teeth are too crowded (not straight). We would recommend SmileFast Align (teeth straightening) first to correct the crowding.
5. The current position of the teeth would require excessive tooth reduction (teeth preparation with a dental drill). We would recommend SmileFast Alignment first.
6. The backwards positioning of the teeth will result in excessively thick (unnatural) veneers which may affect speech - We would recommend SmileFast Align first.
7. There is no room for any incisal-edge lengthening in the current occlusal/incisal scheme (biting position). This case is more complex and would be more suitable for a full-mouth rehabilitation which would include restoration on the back teeth also. We would recommend SmileFast In-Direct (Ceramics) to begin planning this.
The goal of SmileFast dental treatment is to provide a significant cosmetic improvement in the appearance of primarily the front teeth. Full correction of issues such as those listed above may require you to attend for more advanced treatment planning by a Dental Professional and may require different types of dental treatment to correct. As such this treatment is not a replacement for conventional dental techniques but is offered as an additional option.
If you decide to proceed with this treatment, there are obligations you must agree to uphold. If these obligations are not met, your dentist reserves the right to terminate or postpone your treatment.
These obligations include:
Good mouth hygiene: It is important that your mouth and gums are cared for to a high standard. We recommend a dental hygienist appointment before and after SmileFast to ensure you maintain good oral care yourself. Inadequate oral hygiene could result in cavities, discoloured teeth and/or gum disease. An interdental brush is one of the best devices to help keep around your teeth and gums clean and a hygienist can show you the best way to use this.
Food types/Habits: Be very careful what types of food you eat. Hard foods such as crusty bread, popcorn, ice, boiled sweets, toffee etc can break/damage the composite veneers.
Habits: Nail biting, pen chewing and night grinding of your teeth- These habits will increase the risk of the SmileFast composite breaking or chipping.
Nerve Damage: A tooth that has been traumatised by an accident or deep decay may have experienced damage to the nerve of the tooth. This may not be obvious at the start of the treatment as quite often there are no obvious symptoms or signs. Further treatment may then need to be carried out on this tooth. Root canal treatment may be required (at extra cost).
Appointments: It is very important that you attend the appointments as advised by your dentist. Failure to do so may result in delay to your treatment and may require us to take other measures or terminate treatment which may incur additional costs.
Life-Span: Composite dental restorative material will last very well in a healthy and well-cared for mouth. Nothing in dentistry lasts forever but we expect an average of 5 years from SmileFast Direct composite restorations. Within that time there may be additional repair and maintenance costs involved.
Things You Should Know About SmileFast Direct:
As with most dental procedures, SmileFast Direct Composite veneers require some minor tooth preparation toallow them to achieve the desired aesthetic changes to your smile. There are risks associated with teeth from any dental procedure. These are but not limited to increased sensitivity, food trapping and difficulty cleaning, sore gums, tooth nerve damage, change in colour or texture, composite chipping.
Composite bonding is an irreversible procedure. Once the material is bonded to the tooth it can only be removed by carefully drilling it away from the tooth. Preventing minor damage to the underlying tooth during the removal process cannot be guaranteed. Composite restorations will require repair, maintenance and ultimately replacing at some point in the future as they will not last forever. Once the teeth have composite veneers they will need new replacement veneers in the future at some point. You must be aware of the future cost implications for this.
Any restoration placed onto a tooth will increase the chance of dental decay. You must maintain proper oral hygiene. Failure to do so can cause decay and gum disease. The new restorations may have a mild effect on speech and there will be an adaptation process.
If you have any questions regarding your diagnosis or your treatment plan please discuss this with your dental provider before proceeding further.
I give my dentist the right to change treatment at any time during the procedure after discussion with me in certain circumstances during the procedure or any other situations that might arise. This will be in consideration of what is best for my result and the long–term success of the treatment.
Patient signature .*
Consent
I HAVE READ THIS PATIENT AGREEMENT AND FULLY UNDERSTAND ITS TERMS.
Date
MM slash DD slash YYYY
Patient Smile Evaluation
Are you embarrassed about your smile?
- Yes
- No
Do you smile without showing your teeth or cover your mouth when smiling?
- Yes
- No
Does your smile and your teeth make you feel sad?
- Yes
- No
Do you dislike the colour of your teeth?
- Yes
- No
Do you feel you have crowded teeth?
- Yes
- No
Do you feel you have spaces or gaps between your teeth?
- Yes
- No
Do you want ‘perfect’ or ‘Hollywood’ Teeth?
- Yes
- No
Do you want natural-looking teeth?
- Yes
- No
Do you like your teeth in general, but just wish they were a little straighter and whiter?
- Yes
- No
Do you mostly dislike your teeth and feel they need a complete overhaul?
- Yes
- No
Do your teeth cause you pain or discomfort?
- Yes
- No
Have you seen a dentist and hygienist in the last 6 months?
- Yes
- No
Do you have a job which where your speech or elocution is vital?
- Yes
- No
Do you wish to keep your treatment a secret?
- Yes
- No
Do you have a budget in mind?
- Under £2000
- £2000-4000
- Over £4000
Have you a time-frame in mind to complete your new smile?
- Within 6-weeks
- In under 9-months
- Happy to take as long as necessary
How soon would you like to start the treatment?
- Immediate
- In the next 3 months
- Later this year
- No urgency
Email
This field is for validation purposes and should be left unchanged.

Consent Forms

Your Details

Denture Consent

Periodontal treatment consent

Tooth Whitening Consent

Crown Consent

Extraction Consent

Radiography Consent

Root Canal Patient Consent

Inman Aligner

Six Month Smile Patient Agreement

iTero informed consent

Patient’s informed consent and agreement regarding iTero® intraoral scan

Informed Consent

Privacy Notice

Invisalign informed consent

Device Description

Procedure

Benefits

Risks and Inconveniences

Informed Consent

Privacy Notice

Direct Access Hygienist Consent

Background

Direct Access

Referral to dentist

Direct Access Periodontal Treatment Consent

Intravenous Sedation Consent

What is Intravenous Sedation?

Risks

On the day of your treatment

After your treatment under sedation

Emergency Appointment Consent for Non-Registered Patients

SmileFast Direct - Patient Consent Form

What is SmileFast Direct

Limitations

These obligations include:

Things You Should Know About SmileFast Direct:

Patient Smile Evaluation