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ORTHODONTIC TREATMENT TERMS AND CONDITIONS

Beautiful Smile Dental Surgery

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Patient Name *

First

Last

Date of Birth *

Email *

Orthodontic Treatment Terms And Conditions

Treatment Plan Agreement: *

The patient acknowledges and agrees to the orthodontic treatment plan outlined by Dr Saba. Any modifications to the treatment plan will be discussed and agreed upon by both parties.

Payment Terms: *

Payment for orthodontic treatment is to be made in accordance with the agreed-upon schedule. Failure to adhere to payment terms may result in a delay or suspension of treatment

Appointment Attendance: *

The patient is responsible for attending all scheduled appointments for adjustments, assessments, and any other necessary orthodontic procedures. Braces Bonding and Debond appointments (almost 2 hourduration) are made on week day only. Recall appointments can be made on Saturdays , however unjustified cancellation will incur cancellation fee .

Treatment Duration: *

The duration of orthodontic treatment is an estimate provided by the dentist. Factors such as patient compliance and biological response may influence treatment time. Any extensions or alterations to the treatment duration will be communicated to the patient.

Oral Hygiene and Appliance Responsibility: *

The patient is required to maintain proper oral hygiene throughout the treatment period. Failure to comply with oral care instructions may affect treatment outcomes and patient will beresponsible for dental treatment to treat the resulting condition. Patients are responsible for the care and maintenance of any orthodontic appliances provided. Any damage resulting from negligence or misuse may incur additional charges for repairs or replacements.

Emergency Care: *

In case of orthodontic emergencies, patients should contact Beautiful Smile Dental Surgery promptly. All after hours emergencies, should be communicated via email with accompanying clear photos. This information will help in assessing the situation and determining the most suitable scheduling for appointments. We will prioritize emergency appointments however cannot guarantee same-day emergency appointments.

Treatment Completion and Retention: *

Following the completion of active orthodontic treatment, the patient is required to adhere to the retention plan provided. This may involve the use of retainers or other devices to maintain the achieved results. . Non-compliance may lead to relapse, for which we cannot be held responsible, and additional charges may apply for correction.

Termination of Treatment: *

Beautiful Smile Dental Surgery reserves the right to terminate orthodontic treatment if the patient fails to comply with the terms and conditions outlined herein or engages in behaviour that jeopardizes the success of the treatment. In such cases, any outstanding payments will have to be paid in full.

Refund Policy: *

In the unforeseen event of patient relocation or significant changes in circumstances, requests for a refund of orthodontic treatment fees will be assessed on a case-by-case basis. The decision regarding a refund will be made at the discretion of Beautiful Smile Dental Surgery, taking into consideration the individual circumstances. Please note that refunds may or may not be granted based on the evaluation of each case.

Privacy Policy : *

Beautiful Smile Dental Surgery is committed to safeguarding your privacy and ensuring the confidentiality of your personal information according to Privacy Act 1988 (Cth) (Privacy Act). We only collect necessary data for providing dental care and processing administrative tasks. Your information will never be shared with third parties without your explicit consent, and we employ industry-standard security measures to protect it. For more information refer to our Privacy Policy

CONSENT *

By checking the boxes and signing below I acknowledge I have read, understand and Agree to all terms and conditions and consent to the Orthodontic Treatment.

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Print Full Name

Date *

Dr Amtul Saba
17/254 Pitt St, Merrylands NSW 2160
Ph: 0296378077
E: admin@beautifulsmiledentalsurgery.com.au
https://beautifulsmiledentalsurgery.com.au/

Beautiful Smile Dental Surgery

Contact Us

0296378077

admin@beautifulsmiledentalsurgery.com.au

Opening Hours

Monday | 9am – 6pm

Tuesday | 9am – 6pm

Wednesday | 12pm-7pm

Thursday | 12pm – 7pm

Friday | 12pm – 7pm

Saturday | 9am – 5pm

Sunday | Closed

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