SureSmile® Consent Form

SureSmile® Consent Form

Congratulations on your decision to pursue orthodontic treatment for you or your childSureSmile Aligner is an excellent choice made by your care provider to create beautiful new smilesPlease read the following information and make sure that you ask any questions or raise any concerns you may have before signing the consent agreement


1) Failing to follow doctor instructions may interfere with achieving treatment objectivesThis includes not wearing appliances as directed or missed appointments. All treatment times are estimated and may be extended by eruption of teeth or issues related to patient's specific dentition including uncommon tooth shape and any other anomaly encountered during treatment.

2) Inadequate patient oral hygiene during treatment may result in decay gum Imitation, tissue disease or permanent discoloration of teeth. In the event that all hygiene instructions are not followed including regular brushing flossing and regular practice of standard oral hygiene intraoral inflammation or gum disease may result.

3) Minor discomfort when switching aligners during treatment is expectedHowever, any concern regarding pain or difficulty with placing a new appliance should be immediately reported to your care provider or staff. Patients may experience Imitation to gums, cheeks or lips during treatment which should also be communicated to the care provider or staff. Allergic reactions are also possible and should be reported as well.

4) Interproximal (space between the teeth) re-contouring or minor shaping may be required to allow space for teeth to move for proper alignment.

5) Orthodontic treatment involves moving teeth and teeth may shift after treatmentRetainers must be worn at the direction of your care provider to control this tendencyIn short, wearing retainer's post-treatment is essential to maintaining your new smile. 6) In some cases, additional treatment appliances may be required for treatment plans. Such supplemental clinical requirements will be explained by your care provider.These may include the need for oral surgery to correct jaw position or severe crowding which must be completed prior to aligner treatment

7) Notify your care provider of any medical conditions/medications as they could affect treatment.

8) Dental implants cannot be moved by alignersAdditionally, existing restorations may require repositioning or replacement as the result of treatment which may require additional dental surgical or endodontic treatmentIn extreme cases, teeth may be lost.

9) Orthodontic appliances can possibly be swallowed or aspirated. Any looseness
of aligners or any other appliance used during treatment should be immediately
reported to your care provider. In cases involving extreme crowding or missing
teeth, product breakage is more common

SureSmile® Aligner Treatment Informed Consent

Orthodontics is not an exact science, and I acknowledge that my care provider Dentsply Sirona Inc. and its subsidiaries (collectively, "Dentsply Sirona") have not cannot make any guarantee or provide any other assurances regarding the outcome of any treatment. I understand that Dentsply Sirona is not a provider of medical, de or health care services and does not and cannot practice medicine, dentistry or any medical advice.

In signing this document, I am indicating that I understand the risks or options available for orthodontic treatment. Any concerns or questions that I may have had were sufficiently explained by my doctor and I consent to treatment for myself or a minor under my legal care. I also agree that the doctor my or a minor trustee under my care any medical records, including but not limited to, x-rays, reports, charts, medical history, photographs, findings, dental plaster models or impressions, diagnosis, prescriptions, testing and results, billing or any other records regarding treatment in my care provider's possession to other licensed dentists or orthodontists. I also agree that Dentsply Sirona, including but not limited to its employees or of representatives, successors, assigns and investigative agents for the purpose investigating and reviewing of my or my minor trustee for any aspect of my medical history as pertaining to orthodontic treatment with Dentsply Sirona products or educational or research purposes.

I also understand the any use of my medical records may result in the disclosure my or my minor trustee in disclosure of "individually identifiable health information" defined by the Health Portability and Accountability Act (HIPPA"). I will not, anyone acting on my behalf, seek legal, equitable or monetary damages or remedies for such disclosure. I understand that no compensation will be provided for use of medical records, which is without compensation. I acknowledge that I as well anyone on my behalf shall have any right of approval, claim of compensation or seek legal, equitable or monetary damages or remedies resulting from any use compliance with this Consent's terms.

I agree that I have read, understand, and agree to terms stated in this Informed Consent Form as indicated by my signature below, a photostatic copy of this Consent be regarded as effective and valid as an original.