I have read and understand the content of this document describing considerations and risks of clear aligners. I have been sufficiently informed and have been given the opportunity to discuss this form and its contents with the undersigned doctor , and to have my questions adequately answered. I have been asked to make a choice about my treatment, and I hereby consent to receive treatment with clear aligners manufactured by ClearCorrect as planned, prescribed and provided by the undersigned doctor. I agree to follow my doctor’s treatment exactly as s/he plans, prescribes and provides it for me, and I understand that any questions, concerns or complaints I have regarding my treatment must be communicated to my doctor as soon as they arise.
I acknowledge that neither my doctor nor ClearCorrect, its employees, representatives, successors, assigns, or agents, have, can, or will make any promises or guarantees as to the success of my treatment or give any assurances of any kind concerning any pa rticular result of my treatment. I understand that ClearCorrect does not practice dentistry or give medical advice. I understand that ClearCor- rect manufactures medical devices based on instructions from the prescribing doctor. I understand that I should always contact my doctor in the first instance (not ClearCorrect) regarding my expectations, difficulties, results, or any other aspects of my treatment.
I understand that it may be necessary to take impressions, intraoral scans, digital model scans, radiographs (x-rays), and/or photo- graphs for diagnosis, professional review by my doctor or other consulting dentists and orthodontists, and submission to ClearCorrect. I recognize that these will be included in my medical records, which records encompass “in dividually identifiable health information” as that term is defined and protected by the HIPAA Privacy Rule. I understand that my doctor, as a covered entity under HIPAA, is not required to obtain my consent to use and disclose my individually identifiable health information for treatment, payment, and health care operations activities, but has chosen to do so voluntarily through this document. I further agree that my doctor or ClearCorrect may use my medical records for research and educational purposes, but only to the extent that no individual identifiers, including but not limited to my name or address, are disclosed. I hereby consent to such uses and disclosure(s) as described herein.
Unless otherwise permitted or required by law, other uses and disclosures of my medical records, including advertising or marketing by either my doctor or ClearCorrect, shall be made only with my prior written authorization (for which I acknowledge my doctor or ClearCorrect may use my contact information to seek to obtain). I acknowledge I will not, nor shall anyone on my behalf, seek or obtain damages or remedies – legal, equitable, monetary, or otherwise – arising from any use of my medical records that complies with the terms of this Informed Consent and Agreement.
I acknowledge I have read, understand, and voluntarily consent to the use of clear aligners in accordance with the terms of this Informed Consent and Agreement.