Minor & Cosmetic Treatment Patient Consent Form

DOWNLOAD FORM

Instructions: Print all pages after cover

This consent form is to be used for Minor and Cosmetic treatment. This consent:

  • Gains written acknowledgement of the My Smile Choice™ program for either Minor or Cosmetic treatments.
  • Gains patient agreement for treatment compliance.
  • Gains patient permission to use their photos in your marketing of the My Smile Choice™ program.

It is ideal to use this form in conjunction with:

  • MSC Patient Complete Treatment Release Form (optional form)
    • Allows a patient to waive full, recommended treatment & acknowledges the consequences of not opting for complete treatment.
  • Invisalign® Patient Consent Form, available for free on your Invisalign® Doctor Site (IDS): Log in to IDS > Click the support tab > click the printable forms link > download the Invisalign® Patient Consent Form and save it to your computer.
DISCLAIMER
The author of this document and co-founder of My Smile Choice™ was employed by Align Technology, Inc for 13 years to train Orthodontists how to best integrate Invisalign® into their practice, how to clinically set up cases for ideal finishes, and how to treat patients with Invisalign®, she NOT a doctor. Please note that ALL clinical tips given and any clinical advice is to be taken at your discretion. You are the treating doctor and are responsible for your own protocols and treatments.

IMPORTANT NOTICE
My Smile Choice™ is not affiliated with Align Technology, Inc. The statements, views and opinions expressed in this program and related program materials are those of My Smile Choice™. Align Technology, Inc. may not endorse such statements, views or opinions. Program participants are responsible for legal and regulatory compliance of any marketing and referral programs.

INVISALIGN and CLINCHECK, among others, are trademarks or registered trademarks of Align Technology, Inc. in the United States and other countries. All other product names, service marks and trademarks mentioned herein are trademarks or service marks of their respective owners.

At times, aligner manufacturers will make changes to their policies. BrilliantDoc™, the creators of My Smile Choice™, will do its best to inform your practice of anything that might impact the My Smile Choice™ program. But, ultimately, it is your practice’s responsibility to be knowledgeable of such changes and make modifications as needed. If you become aware of any policy changes that impact the overall structure of the My Smile Choice™ program, please notify us at 888-337-6278.