Emergency Palliative Treatment

1. Purpose of Visit & Limited Scope of Treatment

I understand that I am currently a patient of record with another dental/orthodontic provider located outside of this geographic area, and that I am visiting COCO Smiles Orthodontics strictly on a one-time, emergency basis.

I acknowledge and agree that the treatment provided today is strictly limited to immediate palliative care or emergency stabilization. This may include:

• Clipping or covering a poking wire
• Re-cementing a loose or broken bracket
• Re-attaching a loose button or hook
• Temporary comfort measures to alleviate acute pain or irritation caused by existing orthodontic appliances

2. No Ongoing Orthodontic Relationship

I expressly understand and agree that this single emergency visit does not constitute the establishment of an ongoing doctor-patient relationship, nor does it constitute comprehensive orthodontic treatment.

• COCO Smiles Orthodontics is not assuming long-term responsibility for my ongoing orthodontic care, treatment planning, or final clinical outcomes.
• I remain under the primary care of my home-state treating orthodontist/dentist.
• I have been advised to follow up with my primary treating doctor as soon as possible for any further adjustments or continuation of my treatment plan.

3. Limitation of Liability

Because the appliances, wires, brackets, and overall treatment plan were initiated and managed by another provider, COCO Smiles Orthodontics cannot guarantee the integrity, compatibility, or long-term success of materials placed or adjusted during this emergency session.

By signing below, I voluntarily release COCO Smiles Orthodontics, its doctors, and staff from any liability regarding:

1. The long-term outcome or durability of the emergency repair or palliative adjustment performed today.
2. Any unforeseen complications arising from pre-existing appliances or the interaction between emergency fixes and my primary treatment plan.
3. Any future treatment required as a result of the failure of materials placed by another provider.

4. Acknowledgment & Consent

I have read and fully understand this Limited Care Agreement. I confirm that I am seeking only temporary emergency relief, accept the limited scope of today's visit, and voluntarily agree to all terms outlined above.