MYOFUNCTIONAL THERAPY CONSENT FORM

Provided by a Registered Dental Hygienist (RDH)

Client Name:

Date of Birth:

Parent/Guardian (if applicable): __________________________________________________________________________________

Date:

1. Informed Consent for Myofunctional Therapy

I understand that Myofunctional Therapy is a non-invasive treatment focused on improving function and coordination of the oral and facial muscles. The therapy may include exercises, behavior modification, education, and guidance on proper oral habits related to breathing, tongue posture, chewing, swallowing, and speech patterns. The provider will provide the therapies for Orofacial Myofunctional Therapy. Therapy can consist of 3 phases of activities over approximately 4-9 months. The first phase is the high active phase consisting of weekly or bi-weekly sessions.

I understand:

Ø Myofunctional Therapy is not a substitute for medical, dental, orthodontic, or psychological care.

Ø A comprehensive medical and dental evaluation may be required before or during treatment.

Ø No guarantees are made regarding treatment outcomes.

Ø treatment costs and possible outcomes and agrees to pay for the initial intensive phase of therapy to ensure commitment. This initial intensive phase is non refundable.

Ø that therapy is progressive based and takes a commitment in order to be successful. Therapy is self monitored at home between appointments. Compliance is a key part of therapy success.

Ø that therapy will not be successful if appointments are delayed beyond the recommended intervals or abandoned. Compliance is a key part of therapy success.

I voluntarily consent to participate in Myofunctional Therapy services provided by a Registered Dental Hygienist and understand the RDH will work within the scope defined by regulatory bodies and provincial legislation.

I agree to notify my provider immediately if I experience any discomfort or require a change in how care is delivered.

2. Consent for Virtual Therapy

I consent to receive Myofunctional Therapy services through secure virtual platforms. I understand:
- Virtual sessions may be conducted using secure, encrypted technology when possible.
- I am responsible for ensuring a private and quiet environment during sessions.
- Despite best efforts, there is always a risk of data breach or technology failure.
- Virtual therapy may not be appropriate for all situations, and referrals may be made if necessary.

3. Photo, Video, and Media Release

I give permission for photos and/or videos to be taken of me (or my child) during the course of therapy for the following purposes:
- Clinical documentation
- Progress tracking
- Educational use only (presentations, teaching, or training)

I understand:
Images will NOT be used for marketing purposes

☐ I CONSENT to photo/video use as described above

☐ I DO NOT CONSENT to photo/video use

4. Acknowledgment and Release of Liability

By signing this form, I acknowledge that I have had the opportunity to ask questions and understand the nature and scope of Myofunctional Therapy. I release the RDH and clinic from any liability related to participation in therapy, including virtual care or the authorized use of images as noted above. I agree to authorize the provider to obtain and/or release information pertinent to the treatment and observation of the client to other practitioners as it pertains to said treatment

Client Signature: _________________________________________________________________________________________________________

Parent/Guardian (if applicable): __________________________________________________________________________________

Date: _________________________________________________

RDH Name

RDH Signature: ______________________________________________________________________________________________________