Invisalign Consent Form

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The Invisalign consent form is one that gives your healthcare professional the ability to apply all of Invisalign’s components to maximize the results of the process. Invisalign is an aesthetically pleasing alternative to braces, one which requires the patient’s full participation in using the Invisalign aligners to their full potential. The attached document supplies the patient with the financial information as well as the healthcare information associated with this orthodontic application.

Fact Sheet – An information supplement for the use of the patient.

How to Write

Step 1 – Download in Adobe PDF (.pdf).

 

Step 2 – The dental clinic should fill in the majority of the fields of the form prior to the patient’s signatures and initials. The first section is applicable for those receiving Invisalign Full. First the cost of lost aligners will need to be specified.

Step 3 – The full fee for the treatment should be entered next. Below this, the initial payment can be indicated. The progress payment amount can be entered as well, and below that, the average cost for a vivera retainer. When the form has been printed, the patient can print their name, provide the date, and sign where applicable.

Step 4 – If Invisalign Lite is being applied, the lost aligners cost, treatment fee, initial payment, progress payments, and Vivera retainer costs should be specified here. Once again, the patient will need to sign off on these prices.

Step 6 – Under the “Invisalign Teen conditions and costs” section, supply the following costs if applicable:

  • Cost of lost aligners
  • Cost of treatment
  • Initial payment amount
  • Progress payment amounts
  • Retainer costs

The patient must sign off on the costs.

Step 7 – If the patient is going through the Invisalign i7 treatment. The cost of auto refinement must be specified before that of the lost aligners, full treatment and initial payment. Progress payments and vivera retainer costs should be specified as well. Again, the patient must agree to and sign off on these.

Step 8 – The patient must check the applicable box then provide their full name, date, and full address to show they understand that without the proper use of a retainer, the teeth can shift.

Step 9 – With the form printed with the prices in full display, the patient should fill the remainder out by hand. Before they sign off on the costs, they will need to either agree to any necessary attachments or select the teeth on which they do not agree to attachments.

Step 10 – They must also initial next to the below statement to indicate that they will fully. commit to wearing the aligners. Alternatively they may initial next to the second statement to agree to part time where and non-ideal results. After this, they can fill in the other fields and apply their signature to agree to the required costs of their specific Invisalign treatment.