MOD Mouth Clear Aligner Consent Form

How it works

The MOD Mouth Clear Aligner Service is a series of clear, BPA-free plastic aligners made right here in the USA! The MOD Mouth aligners apply mild pressure points to gradually shift and align your teeth for beauty and better oral health. The MOD Mouth clear aligners come in sets and are to be worn in a specific noted sequence. Each step will have a soft aligner for upper and lower teeth followed by a medium aligner for upper and lower teeth. Each set of aligners are worn for 7 days. Each new aligner will modify and gently shift your teeth into a new position. Though every case is different and applies specifically to each client, the process typically takes approximately 4 to 8 months to complete. If you are a MOD Mouth Clear Aligner candidate the treatment setup will follow the MOD Mouth teeth alignment protocol and we may not be able to achieve or meet all specific aspects of your chief complaint. This is due to factors beyond our control, including the protocol and parameters we must follow with MOD Mouth clear aligner treatment. However, we will always have your chief complaint as a point of focus for your treatment, and we will provide you with the best possible results that can be achieved.

Benefits

INVISIBLE – Our aligners are nearly invisible. They are made of transparent clear BPA-free plastic in the USA. The trays are light and airy and nearly invisible when worn.

COMFORT – Our unique aligner system allows for a gentle teeth straightening experience.

HYGIENE – Unlike traditional braces, our clear aligners are removable and can be taken off to eat, drink (everything but clear water) and are removed to brush, floss and rinse your mouth. There are no unsightly, bothersome attachments, brackets or wires placed on your teeth. This allows for proper hygiene and more comfort vs other clear aligner and orthodontic systems.

Risks

As with other orthodontic treatments, MOD Mouth clear aligners may carry some of the potential risks described below:

**You must see a dentist to evaluate your oral health with Xrays, clinical exam and hygiene visits for proper diagnosis of any oral complication and you must address any diagnosed oral diseases prior to the start of aligner treatment.

**It is your responsibility to see a dentist within 6 months prior to starting MOD Mouth Clear Aligner treatment, to verify that your oral health is adequate prior to using MOD Mouth Clear aligners. It is also your responsibility to maintain and have follow-up dental care during and after MOD Mouth aligner therapy


I hereby state that my dentist or hygienist cleaned my teeth within 6 months from starting MOD Mouth clear aligners. My dentist took x-rays of my teeth. My dentist checked for and repaired cavities, loose or defective fillings, crowns or bridges. My dentist checked my x-rays and I have no shortened or resorbed roots. My dentist checked my x-rays I have no impacted teeth. My dentist has probed or measured my gum pockets and says I do not have periodontal or gum disease. My dentist preformed a full oral-cancer screening in the last 6 months and I do not have oral cancer. I have no pain in any of my teeth. I have no pain in my jaws. I have no loose teeth. I have no “baby teeth” and all of my permanent teeth are present.

Informed consent & agreement

I have read and understand the content of this document describing considerations and risks of clear aligners. I have been sufficiently informed and have been given the opportunity to discuss this form and its contents with the MOD Mouth dentist, and to have my questions adequately answered. I have been asked to make a choice about my treatment, and I hereby consent to receive treatment with clear aligners manufactured by MOD Mouth as planned, prescribed and provided by my MOD Mouth dentist following the MOD Mouth Clear Aligner protocol. I agree to follow my clear aligner treatment exactly as s/he plans, prescribes and provides it for me, and I understand that any questions, concerns or complaints I have regarding my treatment must be communicated to my MOD Mouth dentist as soon as they arise.

I acknowledge that neither my doctor nor MOD Mouth, its employees, representatives, successors, assigns, or agents, have, can, or will make any promises or guarantees as to the success of my treatment or give any assurances of any kind concerning any particular result of my treatment. I understand that MOD Mouth may transfer my health and dental records, diagnosis, consultation, treatment, of medical/dental information, both orally and visually, to an affiliated MOD Mouth team member.

I further consent to MOD Mouth sharing my personal and medical information with third parties, business associates, or affiliates for the purposes of treatment planning and/or aligner manufacturing purposes.

I certify that I can read and understand English. I acknowledge that MOD Mouth has not made any guarantees or assurances to me. I have read this form and fully understand the benefits and risks listed in this form related to my use of MOD Mouth aligners. I have had an opportunity to discuss and ask any questions to a MOD Mouth provider about the use of MOD Mouth aligners. I understand that MOD Mouth does not guarantee any specific results or outcomes. I further understand that my MOD Mouth clear aligner treatment will only address the cosmetic alignment of my teeth. Because I am choosing not to engage in comprehensive orthodontic treatment, I understand and accept that my teeth will be straighter than they currently are but may still be compromised.

I hereby grant MOD Mouth the right to use photographs taken of my dental treatment and my first name for educational and/or marketing purposes. I release MOD Mouth from liability for any claims by me or any third party in connection with my participation or use of the clear aligner treatment.

Signature:

Clear