We Smile

We Smiles Pty Limited PATIENT CONSENT


Services

I consent to receive treatment for invisible dental aligners with We Smile. I understand that We Smile offers invisible dental aligners which are manufactured and customised by a laboratory selected by We Smile’s dental practitioners and based on a prescription from a registered dental practitioner and that We Smile does not provide any medical advice.

I understand that the services offered by We Smile are for natural teeth only. I understand that it may be necessary for We Smile to take impressions, scans, x-rays and / or photographs for matters including, but not limited to, diagnosis and professional review, and in order to provide the laboratory it works with the information required to customise invisible dental aligners for my treatment.

Treatment

I agree and understand that the treatment requires me to wear my aligners for 22 hours a day for the duration of my treatment, followed by use of the retainer based on the prescription from a registered dental practitioner.

I accept that the initial predictive smile preview shown to me at the time of my scanning appointment and the We Smile treatment plan that will be emailed or sent via on online link to me following my scan or impressions is an estimate of the final result. I accept that orthodontics is not an exact science and We Smile does not guarantee that the same or similar result will be achieved.

I acknowledge and agree that it will be my sole responsibility to follow my treatment plan and I understand that any questions, concerns or complaints I have regarding my treatment must be communicated to We Smile as soon as they arise. I confirm that all the information I have provided to We Smile, including but not limited to the information I have provided in person or through the www.wesmile.com.au website, is accurate.

Benefits & Risks

I am aware of, and understand, that orthodontic treatment may result in a healthier and more attractive smile, but any orthodontic treatment, including We Smile aligners, also has limitations and potential risks.

Benefits include, but are not limited to, the following:

1. Invisible dental aligners are almost invisible and are therefore barely noticeable;
2. They can be easily removed if required;
3. There are no surprises with the duration of treatment as the treatment plan is fully computerized and patients know exactly what to expect before they begin wearing their invisible dental aligners;
4. They could help to look after your figure as they need to be removed inorder to eat, which could help to limit unnecessary and unhealthy snacks between meals, and..
5. Your oral health could improve as you would be required to rinse your mouth or brush your teeth after each meal.

I understand these risks include, but are not limited to, the following:

1. Treatment time may need to exceed the estimated period;
2. Wearing invisible dental aligners for less than 22 hours per day, excessive bone growth, and
poor oral hygiene may lengthen treatment time, increase the cost, and effect the quality of the
outcome;
3. Unusually shaped, erupting and / or missing teeth can extend treatment times and effect final
results; and
4. Tooth decay, periodontal disease, decalcification (permanent marks), gingival recession or
inflammation of the gums may occur while wearing aligners. This may occur if I consume lots
of foods or beverages containing sugar, if I do not brush and floss my teeth before wearing
my aligners and / or do not maintain regular preventative six (6) monthly check-ups at my
dentist.

I acknowledge and agree that I will notify my dentist immediately if I suffer any side effects.

Additional Costs

I understand that at the end of active treatment, and after the last customised invisible dental aligners
have been fitted, some cases may require refinement with additional invisible dental aligners to
achieve ideal results. There may be additional costs to me if I require such procedures. I must follow
the directions for use (included with each invisible dental aligner package) for best results.

I confirm I have been told by the We Smile hygienist that I should discuss the risks and the contents
of this Patient Consent Form with my dentist.

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Signature Certificate
Document name: We Smiles Pty Limited PATIENT CONSENT
Unique Document ID: 4c28a3d3c9182a3e896b0dfa15db65a8bf510180
Timestamp Audit
October 31, 2018 2:25 pm AESTWe Smiles Pty Limited PATIENT CONSENT Uploaded by Mel Licker - [email protected] IP 103.85.90.2