Consent and signed agreement
Today:
First name:
Surnames:
Birthdate:
Name of your dentist:
Firm:
I hereby certify that I have responded to the smile-online assessment questions with truthfulness and accuracy to the best of my knowledge. I understand that Smile-online .com is applied to natural teeth and that ankylosed teeth and dental implants will not move. I understand that the risks of orthodontic treatment include, but are not limited to, the potential loss of bone or gum tissue, loosening of the teeth, shortening of the roots of the teeth, temporomandibular joint dysfunction or discomfort. Chronic use of anti-inflammatory drugs, aspirin, estrogen, or clacytocin can slow or limit the movement of the teeth. I hereby certify that I have been examined by a licensed dentist during the past year, and do not submit any of the last 6 conditions of the following test as well as any other condition that may affect my medical or dental health or the ability to be properly treated. I understand that I have been advised by Sonrisa-online.com, that the best thing for my interests in dental health would be to have an orthodontic consultation made by a dental professional before buying any aligner or dental positioning system. I certify that I am over 18 years of age and desire not to have an “in person” orthodontic evaluation before purchasing the Sonrisa-online.com aligner system. In the event that you do not proceed with the treatment for a contraindication or any other medical reason, I will seek care and follow-up with my regular dentist. I will not hold Sonrisa-online.com responsible, or any provider or any member of staff responsible for my medical or dental health. I have read and understood the terms and conditions of Sonrisa-online.com (Ortoteamsoft) and I agree to be bound by them. I accept that the prediction positioning is an estimated position and I am not guaranteed that these results will be achieved. I agree to participate in this treatment plan and will not hold Sonrisa-online.com (Ortoteamsoft s.l.) or responsible provider of my medical or dental health responsible.
RETURN THIS DOCUMENT SIGNED WITH YOUR DENTAL IMPRESSIONS
Terms and conditions on the web www.sonrisa-online.com
Answer yes or no to all questions
IF NOT
I have a dental bridge
I have dental restorations, fillings, crowns, veneers, implants.
I have a recent history of jaw blockage or pain (6 previous months).
I have swollen or bleeding gums.
I’m diabetic, although I do not get medical.
I take corticosteroids.
I have had a bone marrow transplant in the last 2 years.
I have had leukemia treatment in the last 2 years.
I am in immunosuppression, chemotherapy or radiation treatment in the head.
I have been treated or I am being, with bisphosphonates (Boniva, Aredia, Zometa, Fosamax)
Please indicate any medical / dental condition that may be relevant
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Do you have a history of dental problems?
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What do you expect from the treatment? 
