Invisalign Instruction Consent Form
Should you decide to not attend the surgery every two weeks and insert the new aligners yourself you MUST inform us if they do not fit properly. If you have any queries regarding this please call the surgery.
Aligners MUST be worn at all times. Under no circumstances should you take them out for over 90 minutes at any one time
Do not drink extremely hot drinks or wash them in hot water as it may warp the aligners.
Should you loose your aligner i.e No. 10 then wear the previous aligner, No. 9 until the new aligner is ordered for you. Replacement aligners will be an extra €200 each
If you take it upon yourself to stop treatment for a period that is longer then recommended by your dentist a charge of €300 may occur as new impressions may need to be taken.
If you do not attend a scheduled appointment or cancel without 24 hours notice a fee of £50 will apply.
You have 180 days from the end of the treatment to inform us if there is any issue with movement otherwise a fee will incur as this is Invisalign’s cut off point.
I am aware that I could use fixed braces (sometimes called “traintracks”) to straighten my teeth and have been given the opportunity of being referred to an orthodontist for this
An important part of orthodontic treatment is creating space for the teeth to move.
This is done primarily by the extraction of one or more teeth or by filing away small amounts of enamel in between teeth.
This is called Interproximal Reduction (IPR).
Here is a photo of what IPR looks like
I understand what Interproximal Reduction (IPR) is yesno
I am happy to have Interproximal Reduction (IPR) completed on my teeth if needed during Invisalign treatment yesno
Attachments are placed on the surface of certain teeth to aid movement
They can be on any of your teeth including front teeth.
These are tooth coloured and removed from your teeth at the end of your treatment.
They will stay on the teeth at all times when you are in treatment.
I understand that I will have attachments placed on my teeth during Invisalign treatment yesno
I understand I may have attachments on my front teeth yesno
Please find below the quotation for your Invisalign treatment with us as per your consultation.
Your quote includes the following
•All of your Invisalign appointments
•Take-home whitening at the end of your treatment
•1 set of removable plastic retainers at the end of your treatment
**permanent retainers are not included as you have to be suitable for these. If you are suitable, there is an extra fee of €150 per jaw **
•Patient DVD, with your clincheck and your before photographs.
*Note by having your impressions taken and sent off to Invisalign you agree to a minimum charge of €1000, if for any reason you decide to cancel your treatment.
Please confirm below your chief dental complaint/reason for Invisalign treatment-
*Quote does NOT include Permanent retainers, Hygiene appointments, translucent attachments and any general dentistry
I have been given enough time to fully understand all issues surrounding my treatment and all options have been explained to me
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Your legal name
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Signed by Nina Bal
Signed On: 8th January 2020
If you have questions about the contents of this document, you can email the document owner.
Document Name: Invisalign Instruction Consent Form
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