Patient election and waiver form

  • I understand:

    (a) That to receive invisible dental aligners with We Smile I must have, or have had, an orthopantogram (OPG) x-ray within the last six (6) months; and

    (b) I am only permitted to select one option below which will be relied upon by We Smile for the purposes of assessing my suitability for the services it offers. I confirm the option I select below accurately reflects my current circumstances (must be completed):

    Option 1
    I confirm that I:
    1. have been examined by a registered dental practitioner within the last six (6) months as of today's date which included an OPG x-ray (which is a panoramic x-ray of all the teeth and the surrounding bones of the face and jaw which used for matters including, but not limited to, orthodontic assessments, evaluations of the wisdom teeth, and periodontal imaging);
    2. do not have periodontal disease or tooth decay;
    3. have received a dental cleaning within the last six (6) months; and
    4. do not have any medical and / or health condition which may affect my ability to, for example, receive the services.

    Option 2
    I confirm that I:
    1. have been examined by a registered dental practitioner within the last six (6) months as of today's date which did not include an OPG x-ray;
    2. do not have periodontal disease or tooth decay;
    3. have received a dental cleaning within the last six (6) months; and
    4. do not have any medical and / or health condition which may affect my ability to, for example, receive the services.

    Option 3
    I confirm that I:
    1. have not been examined by a registered dental practitioner within the last six (6) months as of today's date;
    2. have not had an OPG x-ray within the last six (6) months as of today's date; and
    3. do not have any medical and / or health conditions that may affect my ability to receive the services from We Smile.

    I understand that if the option I select above does not represent my current circumstances then We Smile can, at any time:

    (a) terminate the services it offers to me; and

    (b) will not be responsible for any loss, damage or harm suffered by me as a consequence of the information I have provided.

    I confirm I am aware of the risks of receiving treatment for invisible dental aligners and I have read the Patient Information Sheet.
    I confirm that I:
    1. have been examined by a registered dental practitioner within the last six (6) months as of today's date which included an OPG x-ray (a panoramic x-ray of all the teeth and the surrounding bones of the face and jaw which is used to check for, but not limited to, the length of teeth roots, unerupted teeth, wisdom teeth, and general periodontal evaluations);
    2. do not have periodontal disease or tooth decay;
    3. have received a dental cleaning within the last six (6) months; and
    4. do not have any medical and / or health condition which may affect my ability to, for example, receive the services.
    I confirm that I:
    1. have been examined by a registered dental practitioner within the last six (6) months as of today's date which did not include an OPG x-ray;
    2. do not have periodontal disease or tooth decay;
    3. have received a dental cleaning within the last six (6) months; and
    4. do not have any medical and / or health condition which may affect my ability to, for example, receive the services.
    I confirm that I:
    1. would like to proceed with the We Smile dental check-up in addition to an OPG x-ray and that;
    2. I have not been examined by a registered dental practitioner within the last six (6) months as of today's date;
    2. I have not had an OPG x-ray within the last six (6) months as of today's date; and
    3. I do not have any medical and / or health conditions that may affect my ability to receive the services from We Smile.
  • This field is for validation purposes and should be left unchanged.
Is it for me?