About this template
An orthodontic informed consent form is an essential tool for dental practices and orthodontic specialists before beginning any major treatment plan. This form ensures that patients—or their parents and legal guardians—fully understand the proposed orthodontic procedures, potential risks, expected duration, and financial responsibilities.
Using Doc2Form, practices can quickly deploy this digital consent template to streamline onboarding and maintain clear treatment records. Collecting electronic acknowledgments ahead of time eliminates misplaced paper waivers, reduces waiting room delays, and gives patients ample time to review terms at home. The form covers key treatment variables including appliance care, emergency visits, missed appointments, and explicit authorization to proceed with care.
Whether you operate a solo orthodontic clinic or a multi-provider dental group, establishing a clear paper trail for informed consent protects both the practice and the patient. Customize the sections to match your specific clinical protocols and appliances used, ensuring complete clarity from day one.
Key features
- Collect legally sound treatment acknowledgments online
- Outline specific risks, appliances, and care instructions clearly
- Gather emergency contact and guardian details in one submission
- Streamline pre-treatment paperwork before the patient's visit
- Easily export or archive signed responses for patient charts
Use cases
- New patient consultations for braces or clear aligners
- Parent or guardian authorization for minor orthodontic care
- Pre-treatment risk disclosure and financial agreement sign-off
- Updating consent terms for revised treatment plans
What this form collects
- Patient Full Name (Short answer)Enter the full legal name of the patient receiving orthodontic treatment.
- Date of Birth (Date)Enter the patient's date of birth.
- Parent or Guardian Name (If patient is a minor) (Short answer)If the patient is under 18, please provide the name of the parent or legal guardian completing this form.
- Contact Phone Number (Short answer)Enter the best phone number to reach you regarding appointments or treatment updates.
- Email Address (Short answer)We will send a copy of your submitted responses to this email address.
- Proposed Orthodontic Treatment (Dropdown)Select the primary appliance or treatment type planned.
- Acknowledgment of Risks and Outcomes (Multiple choice)Orthodontic treatment involves moving teeth, which carries inherent risks such as root resorption, gum irritation, or temporary discomfort. Do you acknowledge these potential risks?
- Compliance and Oral Hygiene Agreement (Multiple choice)Patient cooperation is critical. Poor oral hygiene or broken appliances can prolong treatment or cause permanent tooth damage. Do you agree to follow all home-care instructions?
- Agreement to Financial Terms (Multiple choice)Do you understand and agree to the financial arrangement, payment schedules, and fees associated with this treatment plan?
- Medical History Changes (Paragraph)List any recent changes to your medical history, current medications, or known allergies.
- Patient or Guardian Signature (Full Name) (Short answer)By typing your full name here, you certify that you have read, understood, and consented to the proposed orthodontic treatment.
- Consent Date (Date)Enter today's date.
FAQ
What is an orthodontic informed consent form?
It is a formal document used by dental and orthodontic practices to explain treatment procedures, risks, and responsibilities to the patient, securing their written agreement before starting care.
Can parents sign on behalf of minor patients?
Yes. The form includes specific fields for a parent or legal guardian to authorize treatment when the patient is under the age of majority.
How can I customize this form for my orthodontic practice?
You can easily add your clinic's specific policy details, appliance types (such as braces or clear aligners), and custom financial or emergency terms.
How do I share this form with my patients?
You can send the form link via email before their scheduled consultation or embed it in your pre-appointment welcome packet.
Can I save these consent responses to my patient records?
Yes, submissions are automatically organized and can be downloaded or printed for physical or digital patient charts.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.