Download 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
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)