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Medical Disclaimer Form

  1. I hereby certify that I have answered the Become assessment questions truthfully and accurately to the best of my knowledge. I have read the information describing the orthodontic treatment involving “Become invisible aligners” (i.e. the invisible dental aligners) and any related products (collectively the “Become Products”) developed by Optimized Industries Pte. Ltd. (“Become”) attached at Appendix 1 of this Medical Disclaimer Form (the “Form”). I understand the benefits, risks and inconveniences related to the treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment and all my questions have been answered to my satisfaction. I hereby consent to the orthodontic treatment with Become Products. 
  2. I acknowledge that Become has not and cannot make any guarantees or assurances concerning the outcome of the treatment. I acknowledge that Become is generating my treatment plan and producing the aligners. No assurances or guarantees of any kind have been made to me by Become, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment. I further understand that my Become Products will only address the alignment of my front six teeth (upper and lower) and will not correct my existing bite condition (if any), for which I will need to seek more comprehensive treatment from a dental professional. I understand that Become is for natural teeth and that ankylosed teeth and dental implants will not move.
  3. I understand the risks of orthodontic treatment include, but are not limited to, potential loss of bone or gum tissue, loosening of teeth, shortening of tooth roots, and jaw dysfunction or discomfort. Chronic usage of anti-inflammatory medications, aspirin, estrogens, or calcitonin may slow or limit tooth movement. I hereby certify that I have been examined by a licensed dentist within the past year, have received a dental cleaning in the last 6 months, and do not have any of the above conditions or any other condition that may affect my medical or dental health or ability to be treated properly. 
  4. I certify that I can read and understand English, and hereby consent to the disclosures set out above. I certify that I am over 18 years of age and do not wish to have an “in-person” orthodontic evaluation before purchasing the Become aligner system. In the event that I do not proceed with treatment due to a contraindication, treatment or any other medical reason, I will seek care and follow up with my regular dental professional. I have read and understood Become’s Terms and Conditions and agree to be bound by them. I understand that in order to maintain the results of my treatment and to promote further alignment, I agree to either wear a Becomes retainer for 22 hours a day, for 6 months or to use a permanent retainer, prescribed by a dentist. I agree to enter this treatment plan and will not hold Become, any supplier, or any member of staff responsible for my medical or dental health.

Appendix 1 (to Medical Disclaimer Form)

BACKGROUND INFORMATION 

  • Patient’s Informed Consent Regarding Become Orthodontic Treatment
    1. Although orthodontic treatment can lead to healthy teeth and provide important benefits, you should also be aware that orthodontic treatment by way of the Become Products has limitations and potential risks that you should consider before undergoing treatment. You should also be aware of the benefits, risks and inconveniences of alternative forms of treatment which may be applicable to you. 
  • Become Product Description
    1. Become produces the “Become invisible aligners” utilising a set of clear, removable aligners that are custom-made to fit each individual. 
  • Outline of Procedure
    1. Using advanced 3D computer imaging technology, your complete treatment plan (from the initial position of your teeth to the final desired position) can be prescribed.
    2. A set of custom-made Become invisible aligners for your teeth will be produced to move your teeth incrementally to the final desired outcome.
    3. Each set of Become invisible aligners should be worn for at least 22 hours per day for approximately one to two weeks before being replaced by the next in the set until the final position of your teeth is achieved in approximately 6-12 months.
  • Benefits of Procedure
    1. Become Products have been developed especially as a discreet and virtually invisible appliance for patients with unique staging properties. Our Become invisible aligners are: 
      1. Effective.Treatment will provide optimal, precise results in a short span of time. 
      2. Transparent.The materials used are flexible yet discreet. 
      3. Comfortable.The Become invisible aligners are pleasantly smooth, without brackets or wires. 
      4. Removable.The Become invisible aligners can be taken in and out of your mouth quickly and simply at any time (e.g. when you are eating and/or brushing your teeth). 
  • Risks & Inconveniences of Procedure 
    1. Every medical procedure has potential risks. Some of these might also appear when you use Become invisible aligners: 
      1. Uncomfortable feeling in your mouth.The tissue in your mouth, gums, cheeks and lips is sensitive and so it can take a while until you get used to wearing the Become invisible aligners. 
      2. Allergic Reaction.You might be allergic to the materials we use in the Become invisible aligners. If you experience an allergic reaction, please discontinue use of the Become invisible aligners and inform us and your dentist immediately. 
      3. Temporary Side Effects,Because of the presence of the Become invisible aligners, you might experience temporary changes in your speech or saliva flow. 
      4. Periodontal or Gum Disease & Cavities.Cavities, tooth decay, periodontal disease, gingival recession, inflammation of the gums or permanent markings (e.g. decalcification) may occur or accelerate during the use of the Become invisible aligners. This risk increases if you eat and drink a lot of sugary food and beverages, do not clean your teeth and Become invisible aligners, and do not regularly get a check-up from your dentist. You may have to stop the orthodontic treatment and seek the care of a dentist. 
      5. Resorption / Shortening of the Roots.Some patients experience that the roots of their teeth shorten during the orthodontic treatment. This endangers the long-term health of the teeth and could even lead to tooth loss. If your dentists detect resorption during your treatment with Become, you might need to stop treatment. 
      6. Nerve Damage in your teeth.Because of the movement of your teeth, nerve damage might be accelerated. This could result in a loss of your tooth or necessary treatment like a root canal or other procedures. 
      7. Jaw Pain.You might experience pain in your jaw, headaches or ear problems. 
      8. Biting discomfort.Movement of your front six teeth by the Become treatment can slightly change your biting, and can, therefore, result in discomfort during the first few months after the completion of the treatment. Changes in biting require time to get used to. 
      9. Bonded Retainers.The Become invisible aligners cannot move my teeth effectively with these devices in place and they must be removed prior to commencing treatment. 
      10. Other Risks.Like most medical treatments, moving teeth and orthodontic procedures can bear various other risks such as discomfort, swelling, sensitivity and numbness of tissue and jaw and other unforeseen conditions. This might necessitate other additional procedures which are not covered by Become or your dentist. In rare cases, your teeth may not move as expected. Should this happen, Become may provide you with additional treatment to achieve your goals, or offer you a refund of the fees you have paid to Become, both at Become’s sole discretion. 
terms & conditions above and hereby declare that all information provided above is true.