MODmouth Clear Aligner Consent Form

How it works

The MODmouth Clear Aligner Service is a series of clear, BPA-free plastic aligners made right here in the USA! The MODmouth aligners apply mild pressure points to gradually shift and align your teeth for beauty and better oral health. The MODmouth 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 MODmouth Clear Aligner candidate the treatment setup will follow the MODmouth 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 MODmouth 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, MODmouth clear aligners may carry some of the potential risks described below:

  • Treatment time may exceed estimates. Poor compliance to MODmouth instructions, wearing aligners less than 22 hours per day, not presenting to stores for tracking checkups, poor oral hygiene and broken appliances can lengthen treatment time, and negatively affect the quality of the end results.
  • Sores and irritation around the mouth (gums, cheeks, tongue and lips) are possible.
  • Initially, the aligners may temporarily affect your speech. However, clients generally adapt quickly to wearing aligners.
  • While wearing aligners, you may experience a temporary increase in salivation or dryness of the mouth. Certain medications can increase this sensation.
  • In cases of crowding, IPR, also known as interproximal reduction (reducing the thickness of a tooth’s enamel), may be required to create enough space to allow teeth movement.
  • Any medications you may be taking and your overall medical condition can affect your clear aligner treatment.
  • Though uncommon, allergic reactions to the material used during treatment may occur. If you believe you are experiencing an adverse reaction, inform your doctor immediately!
  • Tooth sensitivity and tenderness of the mouth may occur during treatment. This is usually relegated to the instances of advancing from one aligner to the next new set.
  • Bone and gums, both of which support the teeth, can be affected by wearing aligners. In some cases, their health may be impaired or aggravated. If a tooth is not properly covered by an aligner, it may migrate outwards leading to difficulty cleaning, gum disease, and tooth decay. If an aligner is not fitting over all your teeth you must report this to your MODmouth dentist.
  • Wearing aligners may aggravate teeth—previously traumatized or not. Though a rare occurrence, such teeth may require additional dental treatment such as endodontic treatment or other restorative treatment, the useful life of the teeth may be shortened, or the teeth may be lost completely. Existing dental restorations, such as crowns and bridges, may be affected by wearing aligners. They may become dislodged and require re-cementation or in some instances, replacement. Before any dental work such as restorations being replaced or added, consult your MODmouth dentist, as they can affect the way your aligners fi¬t. Aligners will not move dental implants and may not be effective on some dental restorations, such as dental bridges. Additionally, dental restorations, such as crowns, veneers, or bridges, may require replacement due to tooth movement.
  • Root resorption can occur during any type of orthodontic treatment, including clear aligners. Shortened roots are of no disadvantage under healthy conditions.
  • Though rare, problems may occur in the jaw joint, causing joint pain, discomfort, headaches or ear problems. Inform your MODmouth dentist of any such problems immediately.
  • Aligners worn out of their intended sequence can delay treatment results and result in complications including (but not limited to) patient discomfort. Always wear aligners in the order speci¬fied.
  • In some cases, a “black triangle” of missing gingival tissue may be visible below the interproximal contact when teeth are aligned after being overlapped for an extended period of time. This may be corrected with cosmetic dentistry procedures by your regular dentist. Additionally, the tissue attachment between the front incisors may become inflamed which can result following aligner therapy to close spaces or correct overlapped teeth. The procedure known as a frenectomy may be required, and is not a part of the MODmouth treatment, but is a recommended adjunctive treatment for the best outcome and long-term stability of one’s smile.
  • Results may relapse if proper retainer wear is not followed as directed.
  • A successful treatment outcome cannot be guaranteed. After the ¬initial aligners have shipped, some cases may require refinement with additional clear aligners, traditional orthodontic techniques, and/or cosmetic procedures like crowns or veneers to achieve ideal results. There may be additional costs to you if you seek such procedures by your local cosmetic dentist. MODmouth clear aligner treatment will only address the cosmetic alignment of my teeth and will not correct my existing bite condition. In order to correct the current condition of my bite, I will need to seek more comprehensive treatment via a local dental professional.
  • Tooth decay, periodontal disease, decalci¬fication of enamel, gingival recession and inflammation of the gums may occur or accelerate during use of aligners if proper oral hygiene and preventative maintenance are not maintained. This can occur whether wearing aligners or not. These reactions are more likely to occur if your diet includes sugary foods or beverages, or if you do not brush and floss your teeth properly, or if you do not see a dentist for preventative check ups and cleanings at least every six months.

**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 MODmouth Clear Aligner treatment, to verify that your oral health is adequate prior to using MODmouth Clear aligners. It is also your responsibility to maintain and have follow-up dental care during and after MODmouth aligner therapy


I hereby state that my dentist or hygienist cleaned my teeth within 6 months from starting MODmouth 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 MODmouth 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 MODmouth as planned, prescribed and provided by my MODmouth dentist following the MODmouth 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 MODmouth dentist as soon as they arise.

I acknowledge that neither my doctor nor MODmouth, 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 MODmouth may transfer my health and dental records, diagnosis, consultation, treatment, of medical/dental information, both orally and visually, to an affiliated MODmouth team member.

I further consent to MODmouth 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 MODmouth 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 MODmouth aligners. I have had an opportunity to discuss and ask any questions to a MODmouth provider about the use of MODmouth aligners. I understand that MODmouth does not guarantee any specific results or outcomes. I further understand that my MODmouth 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 MODmouth the right to use photographs taken of my dental treatment and my first name for educational and/or marketing purposes. I release MODmouth from liability for any claims by me or any third party in connection with my participation or use of the clear aligner treatment.

MOD Mouth client responsibilities

I understand clear aligners will not work as planned if I do not wear aligners all the time, except when I eat, drink anything but clear water, and when brushing my teeth. In addition, I am responsible to make certain I am wearing aligners that fit properly, as instructed at my scan visit. I am to check the fit of each new aligner when it is inserted. If there is a fit issue I will use Chewies, as instructed. If the new aligner does not seat fully I will continue wearing the previous aligner and contact MOD Mouth immediately.

I understand that if I am not compliant with the above, I will be responsible to pay for additional aligners if they are needed.

Signature:

Clear