Dr. Neille Sherwin B. Paduata,DMD Contact No.

0917-527-0443
Dentist 0977-833-8981
______________________________________________________________________________

ORTHODONTIC TREATMENT GUIDELINES

PATIENT’S RESPONSIBILITIES

The patient (including his/her parents / guardians) is held responsible for the
maintenance of his/her gingival and periodontal health for the duration of the treatment.
Proper tooth brushing, flossing, etc. are mandatory. Adequate oral hygiene education will be
given to the patient and his parents. Should the patient exhibit gingival irritation and or
inflammation due to improper hygiene, active treatment will be discontinued. Proper therapy
shall be performed and the patient will be billed correspondingly.

The patient must strictly follow appointments. The length of treatment will be
affected tremendously should the patient miss his/her appointment. If the patient fails to
come after four (4) consecutive missed appointments or after two (2) months of absence
the treatment plan will be altered. Should the patient wish to continue, a new fee will be
structured to conform to the new treatment plan. If the patient wishes to discontinue, all
previous fees will be forfeited in favor of the dentist.

Appointments are usually made 3-4 weeks after each visit. Should the patient wish to
move the appointments, it should be done at least 24 hours prior to appointment.

ORTHODONTIC FEES:
Orthodontic fees consist of an initial fee and monthly payments to complete the total
orthodontic fee for a particular case. The orthodontic fee covers all orthodontic materials
and procedure for a particular plan only. Lost or damage brackets, molar/buccal tubes, etc.
shall be replaced and the patient billed correspondingly. All other treatment procedures are
not included in orthodontic fees.

FINANCIAL ARRANGMENET:
Total gee for active treatment and retention _______________________
Initial payment _______________________
Monthly payment _______________________

Patient’s name _________________________________ Date:_____________

Parents’s name ________________________________ Signature:
_____________________
 I understand that _______________________________ will use his/her knowledge, skill and
training to do his best, but the relapse of treatment results is possible. Severe problems have a tendency
to relapse and most common area for relapse is the lower teeth. Full cooperation in wearing retaining
appliance is essential in minimizing this relapse. If retaining appliances are lost or broken and not
reported immediately so new ones can be forms, relapse changes may occur requiring appliance
reinsertion and additional fee for correction.

I understand what the problem is and the reason for the treatment. The alternatives have also
been explained to me, one of which is no treatment and the possible result if nothing is done. The
treatment plan and the type of appliances to be used have been explained to me. I also understand that
good oral hygiene at home is important to prevent staining and decalcification of teeth and that in some
patients, temporomandibular joint problems may occur.

I have read and understand the above and consent to treatment

Patient: ______________________________________
Signature over printed name

Parent/Guardian: ________________________________
Signature over printed name

Date: ___________________________________