Download Authorization Form - Roanoke Valley Orthodontics

Dr. David L. Jones &
Dr. Maston R. McCorkle
540.563.1640 | [email protected]
Authorization Form
Please read each authorization request and circle either “Yes” or “No” on the line and then sign the bottom of the form.
You have the right to revoke these authorizations in writing at any time; however, any information already received will
not be covered under that revocation. You also have a right to a copy of any information we have provided.
PATIENT (S)________________________________________________
___Yes/No__ I request and give my permission to Roanoke Valley Orthodontics to provide copies of all orthodontic
records with the respect to the orthodontic care of the above mentioned patient(s) to other dental offices and insurance
companies. Such records may include, but not be limited to, medical care and treatment, illness or injury, dental and
orthodontic history, medical history, financial history, consultation, prescriptions, x-rays and models.
___Yes/No___ I authorize the release of any information from other treating dental offices regarding the dental history
and/ or treatment of patients(s) above, to Roanoke Valley Orthodontics, for the purpose of verifying, evaluating or
treating the above mentioned patient(s).
___Yes/No___ I authorize Roanoke Valley Orthodontics to publish photographs taken of me for use in:
(Check any you agree to)
_______ Inner-office photos
_______ Office publications
_______ Social media sites such as Facebook
_______ Office website
_______ Marketing
_______ Orthodontic publications
__Yes/No___ I acknowledge and agree that publication of photographs confers no rights of ownership or royalties
whatsoever. I hereby release Roanoke Valley Orthodontics and any third parties involved in the creation or publication
of marketing materials from liability for any claims by me or a third party in connection with my participation. I do not
expect any compensation for the use of these photographs.
__Yes/No____ I authorize Roanoke Valley Orthodontics and OrthoIntouch, our Automated Texting and Emailing System,
to send appointment reminders and other orthodontic related reminders, including those with messages, to my cell
phone, any other cell numbers and email I provided on the Patient History Form.
____YES_____ I authorize Roanoke Valley Orthodontics to take photographs, slides, videos and or x-rays of my face,
jaws, mouth and teeth, before, during, and after treatment. I understand that these items will be used as a record of my
care and may be used for educational purposes in study club meetings, lectures, seminars, and demonstrations. I further
understand that if these items are used in any way, my name or other identifying information will be kept confidential
unless I sign a release. (This is required as part of treatment)
_________________________________________________
Signature of Responsible Party
_________________________________________
Date
4370 Starkey Road, Suite C, Roanoke, Virginia 24018 | 6220 Peters Creek Rd. N.W., Roanoke, VA 24019 | 490 S. Main St., Suite 202, Rocky Mount, VA 24151
roanokevalleyortho.com
Dr. David L. Jones &
Dr. Maston R. McCorkle
540.563.1640 | [email protected]
INFORMED CONSENT
ORTHODONTIC TREATMENT PRODUCES SIGNIFICANT IMPROVEMENT FOR PATIENTS. THE BENEFITS OF A PLEASING SMILE AND HEALTHY TEETH ARE WIDEL
APPRECIATED. HOWEVER, ORTHODONTIC TREATMENT IS AN ELECTIVE PROCEDURE. THERE ARE SOME UNAVOIDABLE RISKS AND LIMITATIONS YOU
SHOULD BE AWARE OF BEFORE STARTING TREATMENT.
LACK OF PATIENT COOPERATION- THE MOST COMMON CAUSE OF PROLONGED TREATMENT AND POOR RESULTS
Practicing good oral hygiene, keeping regular appointments, wearing elastics, appliances, or headgear, and avoiding improper foods are all essential for a good result.
Failure to cooperate will result in a compromised result, extend treatment, and result in additional expense.
TOOTH SCARRING- DECALCIFICATION AND DECAY
Poor tooth brushing and excessive sugar in the diet will produce permanent scarring and staining of the teeth and can require restorations (fillings). Proper brushing,
flossing, limiting sugar in the diet, and reporting any loose braces will help prevent scarring.
HEADGEAR-INSTRUCTIONS MUST BE FOLLOWED CAREFULLY
The elastic force must be released before the headgear is removed or it can snap back and cause severe injury to the mouth, face, or eyes. The headgear should not be
worn during rough play or sports that might cause falls or collisions.
IMPACTED TEETH-TEETH UNABLE TO ERUPT NORMALLY
In attempting to move impacted teeth, especially canines, various problems are sometimes encountered which may lead to damage or loss of the tooth or adjacent teet
Also, problems with the supporting bone and gum tissue may develop. Rarely, these teeth will not move.
DEAD TEETH-USUALLY TEETH THAT HAVE BEEN INJURED
Teeth can die over a long period of time with or without orthodontic treatment and require root canal therapy. Teeth with fillings, or a oral history of trauma are more
likely to be affected.
SHORTENING OF ROOTS-ROOT RESORPTION
The roots of teeth can become shorter with or without orthodontic treatment. Under healthy conditions the shortened roots usually are no
problem, but can result in tooth loss. Accidental injury, surgical procedures, impaction, medical disorders, or unknown reasons can cause this problem.
POST TREATMENT TOOTH MOVEMENT-RELAPSE
Teeth will shift or settle after treatment and retention. Some changes may be desirable, but others will not. Rotations and crowding of the front teeth are common.
Slight spaces where teeth were removed can remain. Proper retainer wear prevents relapse.
UNFAVORABLE FACIAL GROWTH-POOR JAW RELATIONSHP
The position of the jaws in relationship to each other determines how well the teeth can fit together. If the jaws do not develop in a favorable position, the orthodontic
result can be compromised. Unfavorable growth of the jaws before, during, or after treatment may necessitate surgery to correct the bite.
TEMPOROMANDIBULAR JOINT (TMJ)-JAW JOINTS
Popping, clicking, locking, and pain can develop in the jaw joint and surrounding structures. These symptoms may exist before, during, or after orthodontic treatment.
While tooth position or bite problems may contribute to these symptoms; non-dental factors such as psychological stress, arthritis, injury, or structural problems can als
be involved. Clenching or grinding the teeth may also be associated. Orthodontic treatment may or may not correct TMJ symptoms.
GUM DISEASE-PERIODONTAL DISEASE, LOSS OF BONE AROUND THE TEETH
Periodontal disease results in the loss of support for the teeth and may exist before, during, or after orthodontics. A periodontics or dentist must evaluate patients with
periodontal disease before orthodontics can be started. Good oral hygiene can help control periodontal disease, but gum and bone support can sometimes be lost
during orthodontic treatment, and teeth can be lost.
APPLIANCE REMOVAL
When removing bonded brackets or bands, enamel flaking or fracturing can occur. This risk is highest for teeth with large restorations or root canals, which tend to
weaken the enamel.
UNUSUAL OCCURRENCES-VERY RARELY ORTHODONTIC APPLIANCES, DENTAL RESTORATIONS, OR CHIPPED TEETH CAN BE SWALLOWED OR ASPIRATED
AND COULD REQUIRE EMERGENCY MEDICAL TREATMENT.
DENTAL CHECK-UPS
All required dental work must be completed before orthodontics can begin. Patients must continue to visit their regular dentist while undergoing orthodontic treatmen
IF YOU HAVE ANY QUESTIONS ABOUT ANY OF THE ABOVE, PLEASE ASK DR. M. R.McCORKLE OR DR. DAVID L. JONES
I have read and understand the above and consent to treatment of :
I consent to the taking of photographs and x-rays before, during and after
treatment, and to the use of same by the doctor in scientific papers or
___________________________________
demonstrations.
Patient's Name
___________________________________
I certify that I have ready or had read to me the contents of this forms and
Patient - Parent - Guardian Signature
do realize the risks and limitations involved, and do consent to
___________________________________
orthodontic treatment.
Date
4370 Starkey Road, Suite C, Roanoke, Virginia 24018 | 6220 Peters Creek Rd. N.W., Roanoke, VA 24019 | 490 S. Main St., Suite 202, Rocky Mount, VA 24151
roanokevalleyortho.com