PATIENT INFORMED CONSENT AND RELEASE FORM
I have voluntarily chosen to consider cosmetic-related dental products, services and/or treatments. My goal in considering cosmetic-related dental products, services and/or treatments is as follows:
TEETH ALIGNMENT/ TEETH WHITENING
As a result, I am voluntarily attending either an in-person evaluation at a SmylUSA LLC clinic or virtually attending an evaluation through the SmylUSA LLC website or any other SmylUSA LLC online technological platform. I understand that an in-person or virtual examination by a licensed dental professional may be necessary to determine my fitness and suitability for the cosmetic products and/or treatments (“Products/Treatments”) that may be rendered upon my approval. Thus, I hereby give my consent to SmylUSA LLC and its designated licensed dental professionals [INSERT DENTAL PROFESSIONAL NAME] to examine me for purposes of assessing, studying, and if warranted, prescribing and/or recommending a course of Products/Treatments for me as follows:
CLEAR ALIGNER TREATMENT/ TEETH WHITENING TREATMENT
____________________________________________(“RECOMMENDED PRODUCTS/TREATMENTS”) and any such additional services as may be considered necessary to accomplish my goals with respect to well- being based on findings made during the course of the Recommended Products/Treatments. The nature and purpose of the Recommended Products/Treatments have been explained to me and no guarantee has been made or implied as to result or satisfaction. I have been given satisfactory answers to any questions, and I hereby knowingly and voluntarily provide my consent to proceed with the Recommended Products/Treatments. If deemed necessary by the licensed dental professional, I also consent to the administration of local anesthesia during the performance of the Recommended Products/Treatments.
II.RISKS AND COMPLICATIONS
I understand that there are risks and complications associated with the Recommended Products/Treatments. I agree that by signing below, I knowingly and voluntarily assume the risk as stated. The potential risks and complications, include, but are not limited to, the following:
- Damage to adjacent teeth or tooth restorations.
- Sensitivity of teeth.
- Chipping, breaking or loosening of the veneer.
- Injury to soft tissues adjacent to veneer due to bonding or bleaching agents.
- Inability to exactly match tooth coloration.
- Changes in the shade, aesthetics, and appearance of the restoration, which may occur over time.
- As a result of the injection or use of any local anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.
- Discomfort or pain caused by any Recommended Products/Treatments.
- Product defects.
- Lack of satisfaction with appearance of teeth in general despite good-faith efforts to achieve patient’s cosmetic goals.
By signing below, I understand and agree that it is my responsibility to:
- *Follow brushing and oral hygiene instructions that are given, to reduce or avoid harm to gums, tissues and teeth;
- *Adhere to any dietary restrictions to keep from damaging teeth and any cosmetic products;
- *Reliably attend any appointments, and reliably/regularly ensure correct use of Recommended Products/Treatments;
- *If warranted, wear elastics, retainers, and headgear, if they are necessary, so treatment time will be as short as possible and to achieve best results; and
- *Visit my general dentist at least every six months for cleaning and examination.
- *Promptly notify SmylUSA LLC or its licensed dental professional of any problems.
- *Cooperate and comply with licensed dental professional recommendations.
By signing below, I knowingly and voluntarily authorize SmylUSA LLC and its designated licensed dental professionals to conduct the examination necessary to determine what, if any, Recommended Products/Treatments may be suggested to help achieve My Goals. By signing below, I further knowingly and voluntarily authorize SmylUSA LLC to release the results of any such examination to any laboratory or other third-party vendor for the limited purpose of conducting any ongoing or further evaluation/analysis, or for the servicing, development and delivery of any Recommended Products/Treatments that I choose to accept and/or purchase for me. By signing below, I knowingly and voluntarily release SmylUSA LLC and its designated licensed professionals conducting the examination, from any and all liabilities, claims, and causes of action, known or unknown, contingent or fixed, as well as any damages that may result from the examination as well as the Products/Treatments that I agreed to accept and receive. I understand that certain products and/or treatments I agree to accept and receive may be manufactured and/or delivered by third parties; thus, to the extent SmylUSA LLC is not the manufacturer or delivering agent, I agree to waive any rights or claims relating to product defects, delivery problems or other related claims or damages against SmylUSA LLC or its designated licensed dental professionals.
V.PAYMENT FOR TREATMENT; TERMINATION
I understand that either me or SmylUSA LLC may terminate the relationship at any time, for any reason, upon notice to the non-terminating party. At all times, I understand and agree that I will be solely liable and responsible for ensuring payment is rendered in full on a timely basis for the Products/Treatments provided, ordered and/or rendered to me up through the date of termination.
PATIENT NAME: _____________________________
PATIENT DATE OF BIRTH: ____________________
PATIENT SIGNATURE: ________________________
SIGNATURE DATE: ___________________________