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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 1. Dental classification a. List….. 2. Habits a. List…. 3. Range of motion a. Maximum opening b. Lateral excursion 4. TMJ (jaw joints) a. List…. 5. Face a. List…. 6. 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. …2 Page 2 Proposed Orthopedic/Orthodontic Treatment Plan 1. Diagnostic Records 2. Consultation a. Orthodontics b. Oral Surgery c. Physician – Airway evaluation (possible nasal obstruction) d. Extraction decision (teeth removal indicated for orthodontic purposes) e. Treatment plan 3. Oral Surgery a. Upper labial frenum b. Tongue frenectomy 4. Orthopedic/Orthodontic Treatment a. Phase I: i. Functional Jaw Orthopedics (Inform before you perform) ii. Fixed Brackets b. Phase II: Functional Jaw Orthopedics i. Advance lower jaw ii. Correct bite c. Phase III: Fixed Brackets d. Air Rotor Reduction (ARS) 5. Corrective Jaw Surgery a. Pending cooperation 6. Phase IV: Retention 7. General Dentistry a. Six month intervals before/throughout/following orthopedics/orthodontics b. Periodontal management as indicated c. Cosmetic/restorative dentistry as indicated 8. Removal of wisdom teeth 9. 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 ______________ Date ______________ Patient (if over 18 years of age) ( ) Signature ___________________________________________ 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 ______________ Date ______________ Patient (if over 18 years of age) ( ) Signature ___________________________________________ 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 ______________ Date ______________ ( ) Witness ___________________________________________ Date _____________ ( ) ______________________________________________________ Date ______________ Patient (if over 18 years of age) ( ) Signature ___________________________________________ Parent/Guardian/Responsible Party when patient under 18 years of age 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 ______________ Date ______________ Date ______________ Patient (if over 18 years of age) ( ) Signature ___________________________________________ Parent/Guardian/Responsible Party when patient under 18 years of age ( ) ______________________________________________________ Dr. (First name) (Last name)/(Corporation)