Acknowledgement of Informed Consent

Date

Mr. & Mrs.

Address

Re: DOB:

Dear Parents and (Patient’s Name),

Welcome to our office. Congratulations on your decision to take advantage of the many benefits to be gained from orthopedic/orthodontics treatment.

(Patient’s Name) is about to begin an experience that many have regards as one of the most significant and rewarding in their lives.

I have examined and obtained diagnostic records for (Patient’s Name). We held a consultation to review diagnostic records, discuss mouth conditions and answer your questions.

Your chief concern(s) was alignment of teeth, and general malocclusion (etc.)

Presenting Conditions Include

Dental classification
List…..
Habits
List….
Range of motion
Maximum opening
Lateral excursion
TMJ (jaw joints)
List….
Face
List….
Trauma history

Treatment Benefits

Benefits of orthopedic/orthodontic treatment generally include:

1.Attractive face

2. Broad- full smile

3.Straight Teeth

4.Self-esteem (confidence)

5.Jaw function

Orthopedic/orthodontics has a great impact on personal success.
Treatment results vary with patient cooperation, treatment methods and clinical response.

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Proposed Orthopedic/Orthodontic Treatment Plan

Diagnostic Records
Consultation
Orthodontics
Oral Surgery
Physician – Airway evaluation (possible nasal obstruction)
Extraction decision (teeth removal indicated for orthodontic purposes)
Treatment plan
Oral Surgery
Upper labial frenum
Tongue frenectomy
Orthopedic/Orthodontic Treatment
Phase I:
Functional Jaw Orthopedics (Inform before you perform)
Fixed Brackets
Phase II: Functional Jaw Orthopedics
Advance lower jaw
Correct bite
Phase III: Fixed Brackets
Air Rotor Reduction (ARS)
Corrective Jaw Surgery
Pending cooperation
Phase IV: Retention
General Dentistry
Six month intervals before/throughout/following orthopedics/orthodontics
Periodontal management as indicated
Cosmetic/restorative dentistry as indicated
Removal of wisdom teeth
Plan subject to change with clinical progress

Patient cooperation is key to best results and treatment with Functional Jaw Orthopedic (FJO) treatment. With good cooperation we expect excellent results. Treatment will require approximately (duration).

My staff and I are pleased to welcome you to our office.

We look forward to (Patient’s Name) next appointment.

Sincerely,

Dr. (First name) (Last name)

Address etc.

PROGRESS REPORT

Date

Mr. & Mrs.

Address

Re: DOB:

Dear Parents and (Patient’s Name),

(Patient’s Name) has benefited from orthopedic/orthodontic services. We planned treatment as follows:

Diagnostic Records
Consultation
Oral Surgery

Arch Preparation
Upper expansion

Lower
Functional Jaw Orthopedics (FJO)

Help TMJD

Expand upper arch
Reposition lower jaw and correct bite
Correct midline
Correct vertical

Fixed Brackets

Level and align teeth

Case finishing

Retain

General dentistry

Resolve third molars (wisdom teeth)

Where we are now:

Comments:

Present Status:

We enjoy working with (Patient’s Name)

Sincerely,

Dr. (First name) (Last name)

Address etc.

ACKNOWLEDGEMENT OF INFORMED CONSENT

CONSENT TO UNDERGO ORTHODONTIC TREATMENT

I hereby acknowledge that the Orthodontic Information, “Your Orthopedic/Orthodontic Treatment” and “You and Your Dentist….Informed Consent for the Orthodontic Patient” outlining major treatment considerations and potential risks of orthopedic/orthodontic treatment has been presented to me. I also understand that there may be other problems that occur less frequently or are less severe. I have read and understand this form.

Dr. (First name) (Last name) has discussed orthopedic/orthodontic treatment with me. I have been asked to make a choice about that treatment for (Patient’s First and Last name).

Dr. (First name) (Last name) has presented information to aid in the decision making process, and I have been given the opportunity to ask Dr. (First name) (Last name)all questions I have about alternative treatment methods, the proposed orthopedic/orthodontic treatment, and the information contained in this form.

I understand that treatment and results are greatly influenced by patients oral conditions, general health, age and cooperation; i.e. brushing teeth/gums, wearing removable braces, splints, headgear and/or elastics, clinic response, keeping scheduled appointments and follow through on referrals to other health care providers.

I further understand that like other healing arts, the practice of orthopedics/orthodontics is not an exact science; therefore, results cannot be guaranteed. Payment of the fee is for services rendered and is not based upon results, which vary with each patient.

I hereby consent to Dr. (First name) (Last name)/(Corporation) and/or such associates and assistants as (he/she) may designate to provide orthopedic/orthodontic treatment for:

( ) Patient’s Signature ______Date ______

Patient (if over 18 years of age)

If you are consenting to the care of another:
I (Parent/Guardian/Responsible Party)have the legal authority to sign this on behalf of
(Patient’s First and Last name).Relationship to Patient: ______

( ) Signature ______Date ______

( ) Witness ______Date ______

CONSENT TO USE OF RECORDS

I hereby give Dr. (First name) (Last name) my permission for the use of (Patient’s First and Last name) orthopedic/orthodontic records including photographs, models and radiographs made in the process of examinations, treatment and retention for the purpose of professional consultations, research, education, professional journals, seminars and presentations.

( ) Signature ______Date ______

( ) Signature ______Date ______
Parent/Guardian/Responsible Party

AGREEMENT TO CONTINUE GENERAL DENTAL SUPERVISION

THROUGHOUT ORTHODONTIC AND TMJ TREATMENT

We require that the teeth be cleaned and all cavities filled prior to commencing fixed bracket therapy.

We recommend 6-month interval visits for general dentistry throughout orthopedic/orthodontic management. During orthopedic/orthodontic treatment, your general dental care is required.

General dental services must be maintained throughout orthopedic/orthodontic treatment:

Cavity check-up
Cleaning
Fluoride
Brushing instructions
Nutritional counseling
Cancer check-up
Traumatic injuries
Fillings
Sealants
Gum treatment(s)
Extractions
School/Camp/Missionary examination
Other

We recommend that a thorough cleaning and nay needed general dental service be performed when orthodontic braces are removed from the teeth.

General Dentistry is a separate insurance benefit.

I agree to complete any needed general dentistry services and to maintain six-month visits with my dentist throughout orthopedic/orthodontic treatment.

( ) Signature ______Date ______
Patient (if over 18 years of age)

( ) Signature ______Date ______
Parent/Guardian/Responsible Party when patient under 18 years of age

Cc: Dr. ______

AUTHORIZATION MEDICAL/DENTAL INFORMATION

Date: ______

Patient Name:______

Insured: ______

Patient Birthdate:______SIN: ______

To whom it may concern:

AUTHORIZATION TO OBTAIN MEDICAL/DENTAL INFORMATION:

I authorize any physician, surgeon, dentist, druggist, hospital, arbitrator, attorney or insurance company to furnish to Dr. (First name) (Last name)/(Corporation)all records in their possession regarding injuries, medical/dental history and physical condition both before and after the above date. This information will be used for diagnosis, verifying, evaluating, negotiating or other pertinent medical/dental and legal uses, with respect to the patient.

AUTHORIZATION TO RELEASE MEDICAL/DENTAL INFORMATION:

I authorize Dr. (First name) (Last name)/(Corporation)to furnish to my physician, surgeon, dentist, druggist, hospital, arbitrator, attorney or insurance carrier all records, opinions, reports, x-rays, photostatic copies, abstracts, excerpts of any records or any other information or documents concerning medical and/or dental history, hospitalization accident reports, account report, treatment or care rendered by Dr. (First name) (Last name)/(Corporation)on behalf of patient. This information will be used for diagnosis, verifying, evaluating, negotiating or other pertinent medical/dental and legal uses, with respect to patient.

If there is any change involved in providing the requested information please forward a bill for such services directly to me (the patient or responsible party).

I, as the patient or authorized representative, have received a copy of this authorization. A photocopy of this authorization shall be accepted as granting the same authority as the original. A copy of this authorization has been received by the patient or authorized representative.

( ) Signature ______Date ______
Patient (if over 18 years of age)

( ) Signature ______Date ______
Parent/Guardian/Responsible Party when patient under 18 years of age

CONSENT FORM FOR AIR-ROTOR STRIPING (ARS)

Dr. (First name) (Last name)/(Corporation)has explained the rationale for electing to use ARS as a treatment option.

I, (Patient/Parent or Guardian Name) ______, give my consent for Dr. (First name) (Last name)/(Corporation)to perform interproximal reduction (removal of slight amount of enamel between the teeth).

I acknowledge that the following has been explained to me and I have had an opportunity to ask questions. Interproximal enamel removal is a procedure to remove a slight amount of enamel between the teeth to create space for the correction of crowded teeth or to enable the teeth in each dental arch to come together more efficiently. This is accomplished with a high-speed dental drill and will not require anesthesia since the procedure is pain free.

The details of the procedure have been described to me by Dr. (First name) (Last name)/(Corporation)after consultation regarding my particular needs.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND THAT I UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE CONSENT FORM. I ALSO STATE THAT I SPEAK, READ AND WRITE ENGLISH.

( ) Signature ______Date ______
Patient (if over 18 years of age)

( ) Signature ______Date ______
Parent/Guardian/Responsible Party when patient under 18 years of age

( ) Witness ______Date ______

( ) ______Date ______

Dr. (First name) (Last name)/(Corporation)

MEDICATION/ARBITRATION AGREEMENT

Date: ______

Patient Name: ______

Patient DOB: ______

To whom it may concern:

Any claim or controversy between the patient and dentist concerning the financial obligations of the patient or the care and treatment rendered by the dentist shall be resolved through mediation or arbitration according to the rules of (Arbitration Association).

A claim or controversy shall first be submitted to non-binding mediation. If the claim or controversy is not resolved to the satisfaction of both parties through the mediation process, it will be submitted to binding arbitration.

Costs for mediation and/or arbitration services shall be shared equally by the parties.

Judgment(s) on the decision achieved through mediation or rendered by the arbitrator(s) can be entered in any court having jurisdiction thereof.

I authorize release of any information relating to this claim.

I, as the patient or authorized representative, have received a copy of this agreement.

( ) Signature ______Date ______
Patient (if over 18 years of age)

( ) Signature ______Date ______
Parent/Guardian/Responsible Party when patient under 18 years of age

( ) ______Date ______

Dr. (First name) (Last name)/(Corporation)