Patient Intake Form

Reference & Image Release

I hereby grant permission to Vakt, Inc to reproduce any portion of the images regarding my dental treatment or myself for the purpose of Marketing and Product Development which can include but is not limited to brochures, books, cards calendars, invitations and websites without any compensation or recognition given to me. Furthermore, I grant creative permission to alter the photograph(s). I also grant use of a written recommendation or reference developed by Vakt, Inc. using my demographic information. I do not grant permission to resale or use the photographs or the recommendation/reference in a manner that would exploit or cause malicious representation toward me. I recognize that I am being compensated for this release through a discounted rate for the product provided by Vakt, Inc. and this represents a full accounting for all compensations for this usage.

Confidentiality

“Confidential Information” means any oral, written, graphic or machine-readable information including, but not limited to, that which relates to prices, patents, patent applications, research, product plans, products, developments, inventions, processes, designs, drawings, engineering, formulae, markets, software (including source and object code), hardware configuration, computer programs, algorithms, business plans, agreements with third parties, services, customers, marketing or finances of the disclosing party, which Confidential Information is designated in writing to be confidential or proprietary, or if given orally, is confirmed in writing as having been disclosed as confidential or proprietary within a reasonable time (not to exceed thirty (30) days) after the oral disclosure.

I agree not to use any Confidential Information disclosed for any purpose other than to carry out discussions concerning, and the undertaking of, the Orthodontic Services. I shall not disclose or permit disclosure of any Confidential Information to third parties. I agree that I shall take all reasonable measures to protect the secrecy of and avoid disclosure or use of Confidential Information in order to prevent it from falling into the public domain or the possession of persons other than those persons authorized under this Agreement to have any such information. Such measures shall include, but not be limited to, the highest degree of care that I utilize to protect my own Confidential Information of a similar nature, which shall be no less than reasonable care. I agree to notify Vakt Inc in writing of any actual or suspected misuse, misappropriation or unauthorized disclosure of Confidential Information which may come to my attention.

Exceptions

(a) Notwithstanding the above, I shall not have liability for any information which is in the public domain at the time it was disclosed or has entered the public domain through no fault of mine; (b) was known to me, without restriction, at the time of disclosure, as demonstrated by files in existence at the time of disclosure; (c) is disclosed with the prior written approval of Vakt Inc; or (d) is disclosed pursuant to the order or requirement of a court, administrative agency, or other governmental body; provided, however, that I shall provide prompt notice of such court order or requirement to Vakt Inc to enable Vakt Inc to seek a protective order or otherwise prevent or restrict such disclosure.

Orthodontic treatment remains an elective procedure with many benefits. Like any other treatment of the body, there are some inherent risks and limitations. These seldom prevent treatment, but should be considered in making the decision to undergo treatment.

Predictable Factors that Can Affect the Outcome of Orthodontic Treatment

Cooperation: In the vast majority of orthodontic cases, significant improvements can be achieved with patient cooperation. Aligners must be worn 22 out of 24 hours a day. The amount of time worn will affect the results. Wear as instructed!

Risks of Any Orthodontic Treatment

Root Resorption: Shortening of root ends can occur when teeth are moved during orthodontic treatment. Under healthy conditions the shorted roots usually are no problem. Trauma, impaction, endocrine disorders or idiopathic (unknown) reasons also cause this problem. Severe resorption can increase the possibility of premature tooth loss.

Nonvital or Dead Tooth: A tooth traumatized by a blow or other causes can die over long periods of time with or without orthodontic treatment. This tooth may discolor or flare up during orthodontic movement and require endodontic treatment (root canal).

Periodontal Problems (gum disease): This condition can be present before or develop during treatment. It could deteriorate during treatment causing loss of bone around teeth. Excellent oral hygiene and frequent prophylaxis by your dentist can help control this situation.

I certify that I have read the contents of this form and do realize the risks and limitations involved, and do consent to orthodontic treatment.