Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Orthodontic Treatment Consent Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Parent or Guardian Name
Treatment Type
Estimated Treatment Duration
Risks and Complications Reviewed
Additional details
Oral Hygiene Requirements Acknowledged
Dietary Restrictions Acknowledged
Financial Agreement Reviewed
Your practice's consent wording goes here.
Signature
Date
Consent to Treatment
Your practice's consent wording goes here.
Signature
Date
Patient or Guardian Signature
Date
Date of Consent
____ / ____ / ________
Orthodontic Treatment Consent Form template from formisoft.com. formisoft.com/intake-templates/orthodontic-consent