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Monacell Orthodontics
ADULT PATIENT
INFORMATION
Smiles Are Our Specialty
Date: __________________
GETTING TO KNOW YOU...
Name: _____________________________________________________ Nickname: ______________________ Birthdate: _______ - _______ - _______
Home Address: _________________________________________________________________ SSN: ______ - _______ - ___________ Sex: __________
City/State/Zip:_________________________________________________________________ Marital Status: __________________________________
Email Address: _______________________________________________________________________________________________________________
Home Phone: ______________________________ Work Phone: ______________________________ Cell Phone: ______________________________
WHAT ARE YOUR GOALS?
If you could change anything about your smile or bite, what would it be? _______________________________________________________________
How long have you wanted to have this changed? __________________________________________________________________________________
What factors have been standing in your way? _____________________________________________________________________________________
Do you have concerns about undergoing orthodontic treatment? _____________________________________________________________________
Has anyone in your family had braces with us before? Please list: ______________________________________________________________________
Who can we thank for referring you to our office? ___________________________________________________________________________________
CONFIDENTIAL RESPONSIBLE PARTY INFORMATION
Name: _____________________________________________________ Nickname: ______________________ Birthdate: _______ - _______ - _______
Home Address: ___________________________________________________________ City/State/Zip: _______________________________________
How long at this address: _______ Previous address (if less than 3 years): ________________________________________________________________
Mailing Address: __________________________________________________________ City/State/Zip: _______________________________________
Email Address: _____________________________________ Relationship to patient: ______________________ SSN: ______ - _______ - ___________
Home Phone: ______________________________ Work Phone: ______________________________ Cell Phone: ______________________________
Employer: _____________________________________Occupation: ___________________________________________ Years Employed: __________
Spouse’s Name: _______________________________________________SSN: ______ - _______ - ___________ Birthdate: _______ - _______ - _______
Employer: _____________________________________Occupation: ___________________________________________ Years Employed: __________
Home Phone: ______________________________ Work Phone: ______________________________ Cell Phone: ______________________________
INSURANCE INFORMATION
Policy Holder: ________________________________________________SSN: ______ - _______ - ___________ Birthdate: _______ - _______ - _______
Policy Holder’s Employer: _______________________________________________________Group No: _______________________________________
Insurance Company: __________________________________________________________Subscriber ID: ____________________________________
Insurance Company Address: ___________________________________________________Insurance Company Phone: _________________________
Do you have dual coverage
Y
N
If yes, complete the following:
Policy Holder: ________________________________________________SSN: ______ - _______ - ___________ Birthdate: _______ - _______ - _______
Policy Holder’s Employer: _______________________________________________________Group No: _______________________________________
Insurance Company: __________________________________________________________Subscriber ID: ____________________________________
Insurance Company Address: ___________________________________________________Insurance Company Phone: _________________________
EMERGENCY INFORMATION
Name of nearest relative NOT living with you: ______________________________________________________________________________________
Complete Address: ___________________________________________________________ City/State/Zip: ____________________________________
Home Phone: ______________________________________ Work Phone: __________________________ Cell Phone: __________________________
Relationship to you: ___________________________________________________________________________________________________________
MEDICAL HISTORY
Are you currently seeing a physician or taking medications?
Y
N
If yes, what diagnosis? _________________________________________________________________________________________________
Are you pregnant? Expected due date? __________________________
Y
N
Are you allergic to any medications?
Y
N
Please list with reaction: ________________________________________________________________________________________________
Any known allergies to metals:
Y
N
Please list with reaction: ________________________________________________________________________________________________
Su er from frequent headaches?
Y
N
Describe any injuries to your face or teeth: ___________________________________________________________________________________
Have you had or currently have any history of the following?
Arthritis
Hepatitis
Bone Disorder
Artificial Joint
Diabetes
Herpes/Oral cold sores
Joint Swelling
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Heart Trouble
Ulcers
Neck/Shoulder Pain
Heart Murmur
Sinus Infection
Ear Disorder
Tuberculosis
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
Swollen Glands
Cancer
Asthma
Fainting/Seizures
High Blood Pressure
Rheumatic Fever
Emotional Problems
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
AIDS/HIV
Glaucoma
Psychiatric Treatment
Blood Disorder
Liver Ailment
Speech problems
Sleep Apnea
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
N
N
N
If yes, please describe: _________________________________________________________________________________________________________
Are there any medical issues not listed above? _____________________________________________________________________________________
If yes, please describe: _________________________________________________________________________________________________________
Physician Name: __________________________________________________________ Phone: __________________ Last Exam Date: _____________
DENTAL HISTORY
Dentist Name: ____________________________________________________________ Phone: __________________ Last Exam Date: _____________
Dental treatment that needs to be completed prior to orthodontic treatment?
Y
N
Scheduled date _____________________________
How often do you brush your teeth each day?
Several times
Twice
Once
Less Than Once
How often do you floss your teeth each day?
Several times
Twice
Once
Less Than Once
Have you had or have any of the following habits? (Choose all that apply)
Lip Biting
Y
N
Nail Biting
Gum Chewing
Y
N
Ice Chewing
Y
Y
N
N
Thumb Sucking
Finger Sucking
Y
Y
N
N
Have you ever experienced any of the following? (Choose all that apply)
Ear aches
Y
N
Jaw clicking/popping
Jaw locking
Y
N
Facial muscle pain
Clenching
Y
N
Grinding
Y
Y
Y
N
N
N
Jaw joint pain
Face tightness/sore
Painful chewing
Y
Y
Y
N
N
N
Have you ever been treated for any of the following? (Choose all that apply)
TMJ/TMD
Y
N
Periodontal Disease
Y
N
Bad Breath/Halitosis
Y
N
Have you consulted with an orthodontist previously?
Y
N
Whom/When? ________________________________________________________
If yes, what was it that caused you to seek another opinion? __________________________________________________________________________
ADDITIONAL INFORMATION
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
I, the undersigned, give my permission for treatment from Dr. John Monacell and his staff. I hereby authorize the taking of x-rays and
other diagnostic records for an initial diagnosis if needed. I further acknowledge that the original diagnostic records are by State law,
the property of the practice. I also give my approval and consent for the patient’s name, photographs and other diagnostic material to
be used in scientific, educational, and/or promotional work produced by Dr. Monacell and staff. I hereby authorize payment of
insurance benefits directly to John F. Monacell, D.D.S., P.C., for services rendered to the patient. I also authorize the release of all
patient records or other information necessary to determine benefits payable and/or which may be used for claims data analysis. I
authorize the use and disclosure of protected health information to complete treatment, payment activity, and Healthcare operations.
Signature: _________________________________________ Relationship to Patient: ____________________ Date: ________________
Monacell Orthodontics
Smiles Are Our Specialty
SLEEP ASSESSMENT AND EPWORTH SCALE
Patient Name:_______________________________________
Date of Birth:__________ Height:_________ Weight:___________ Age:__________
Please list any medical conditions within the last 5 years (hypertension, diabetes, surgery, etc.)
_____________________________________________________________________________________
_____________________________________________________________________________________
Choose appropriate response:
Have you suffered a heart attack or stroke?
Yes
No
When?__________
Do you snore at night?
Yes
No
Occasionally
Witnessed pauses in breathing while asleep?
Yes
No
Occasionally
Do you have difficulty falling asleep?
Yes
No
Occasionally
Do you have difficulty maintaining sleep?
Yes
No
Occasionally
Experience a restless sensation in legs while lying awake in bed?
Yes
No
Occasionally
Kicking and twitching movements while asleep?
Yes
No
Occasionally
Experience excessive daytime tiredness?
Yes
No
Occasionally
Have you ever awakened feeling paralyzed?
Yes
No
Occasionally
Experience a sudden loss of strength in your arms or legs?
Yes
No
Occasionally
If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter?
Yes
No
Check all that apply:
Do you frequently awaken with:
Dry Mouth
Headache
Chest pain
Choking & Gasping
Nasal Congestion
Heartburn
Excessive Sweating
Feeling Groggy & Un-refreshed
According to the following scale, choose the appropriate number value to represent how likely you are
to fall asleep during the day in the following situations. Try to be honest as possible. If possible, have
your significant other help you fill this out.
0-never
1-slight chance
2-moderate
3-always
Sitting and reading
Watching T.V.
Sitting inactive in public (movie theater, meeting)
Sitting and talking to someone
Sitting quietly after lunch without alcohol
As a passenger in a car for an hour without a break
Driving a vehicle for 2 or more hours
Lying down to rest in the afternoon when circumstances permit
Patient Signature _____________________________________
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
Total
________
3
3
3
3
3
3
3
3
Date ____________________
John F. Monacell, D.D.S., P.C.
Specialist in Adult & Child Orthodontics and Dentofacial Orthopedics
1343 East Williamsburg Road  Sandston VA 23150
9448 Chamberlayne Road, Suite B  Mechanicsville VA 23116
(804) 737-6757
www.monacellorthodontics.com
(804) 746-0918
NOTICE OF PRIVACY PRACTICES (HIPAA)
This Notice Describes How Medical Information About You May Be Used And Disclosed And How
You Can Get Access To This Information. Please Review It Carefully.
Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email
addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following
respects:
•
•
•
•
•
•
•
•
•
To other health care providers (i.e. your general dentist, oral surgeon, etc.) in connection with our rendering
orthodontic treatment to you (i.e. to determine the results of cleanings, surgery, etc.)
To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of
flexible spending accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of
payment, etc.)
To certifying, licensing and accrediting bodies (i.e. American Board of Orthodontics, state dental boards, etc.) in
connection with obtaining certification, licensure or accreditation.
Internally, to all staff members who have any role in your treatment.
To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling,
etc.
To your family and close friends involved in your treatment.
To contact you in order to provide appointment reminders or information about treatment alternatives or other
health related benefits and services that may be of interest to you.
To email your x-rays, photos, and treatment plan to your other doctors as needed.
To leave messages or email you regarding upcoming appointments.
Your Rights Regarding Your Health Information
You may ask us to communicate with you in a confidential manner, ask to see or obtain photocopies of your health
information and/or ask us to amend your health information if you feel that it is inaccurate or incomplete.
Acknowledgements and Permissions
Please initial next to each line below
____ I give permission for my/my child’s photo to be displayed in this office.
____ I give permission for my/my child’s photos, x-rays, study models and other diagnostic, treatment and demographic
information to be used for the following purposes: Research, Lectures/Presentations, Publications and Practice
Marketing.
____ I hereby acknowledge the risks of submitting this form and other sensitive personal information via unencrypted email.
I hereby acknowledge that I have received, read and reviewed a copy of this notice of Privacy Practices, the consent to
treatment and office procedures. I authorize use of my signature on and release of information for insurance submissions.
Signature of Responsible Party
Date
John F. Monacell, D.D.S., P.C.
Specialist in Adult & Child Orthodontics and Dentofacial Orthopedics
1343 East Williamsburg Road • Sandston VA 23150
9448 Chamberlayne Road, Suite B • Mechanicsville VA 23116
(804) 737-6757
www.monacellorthodontics.com
(804) 746-0918
Monacell Orthodontics
Smiles Are Our Specialty
Date --------
Informed Consent
Orthodontics
Orthodontic treatment can make a beautiful difference in your smile. Treatment can help improve
appearance, health, comfort, and enhance self-esteem. Informed and cooperative patients can achieve significant
improvements. While recognizing the benefits of a pleasing smile, and healthy teeth, you should be aware that
orthodontic treatment has limitations and potential risks. These are seldom enough to prevent treatment, but
should be considered in making the decision to wear appliances for orthodontic treatment. Orthodontic treatment
usually proceeds as planned; however, like all areas of the healing arts, results cannot be guaranteed.
Risks
All forms of dental treatment, including orthodontics, have some risks and limitations. Complications that
occur in orthodontics are infrequent and usually minor. However, you should be aware of these complications
when making the decision to undergo orthodontic treatment. Please read, initial each statement, sign, and
return Informed Consent to our office. If you have any questions regarding any of these issues, please feel free
to ask for clarification.
______ Patient Cooperation
This is the most important factor affecting the length of treatment time. Failure to
wear elastics (rubber bands), removable appliances or headgear as prescribed, breaking appliances (braces) or
missing appointments may prolong treatment and/or prevent anticipated jaw growth or tooth movement. Thus, lack
of cooperation may adversely affect the quality of the result or require alterations in the original plan of treatment.
Surgical assistance may be recommended in some cases.
______ Missed Appointments We cannot be responsible for adverse tooth movement or tooth damage (decay)
due to missing appointments in our office or with the patient's dentist. We cannot stress enough the importance of
continued supervision during treatment. If a problem arises, please call our office.
______ Headgear Careless use of headgear by the patient may result in injury to the mouth, face or eyes. It is
important that patients not wear their headgear during horseplay or competitive activity. Be sure to follow our
instructions carefully. It is important that the amount of time prescribed for the headgear to be worn be followed, as
it will affect the quality of results.
______ Proper Cleaning of Appliances, Teeth, and Gums This is essential. Your dentist must perform a complete
dental check-up and thorough cleaning every 3-6 months during orthodontic treatment. Poor tooth brushing and
flossing will increase the risk of tooth decay or decalcification (permanent white spots).Sore, swollen gums, as well
as periodontal disease (gum disease) can also develop from poor brushing and flossing. Good nutrition is essential.
Sugars and sodas should be restricted, since they promote tooth decay. Report loose bands or appliances
immediately. They may contribute to decalcification or decay.These same problems also can occur in patients not in
braces, but the risk is greater while in braces.
______ Periodontal Problems Swollen, bleeding gums with or without the loss of the bone supporting the teeth
can occur before, during and after orthodontic treatment. Usually, proper brushing and flossing will prevent this
condition. However, there are other health factors (often unknown) that can cause periodontal disease (Pyorrhea).If
periodontal conditions become uncontrollable, treatment may have to be discontinued. In severe cases, teeth may
be lost. Chronically swollen gums, gingival (gum) recession and/or bone loss may require treatment by a
Periodontist (dentist who specializes in treatment of gums). In general, orthodontic treatment lessens the possibility
of tooth loss or gum infection due to malocclusion.
______ Non-Vital or Dead Tooth Trauma by a blow to a tooth can cause a tooth to abscess. Discoloration may
also occur. Orthodontic tooth movement may aggravate the condition of a tooth that was traumatized by a previous
accident or has large fillings, which may have damaged the nerve of the tooth. In rare instances, this may lead to
root canal treatment and a crown may be required to prevent fracture or breaking of the tooth.
___ Root Resorption
Shortening of root ends may occur during orthodontic treatment. Short roots are
usually no problem in healthy gums and bone. Premature or early tooth loss can occur if gums recede or bone
levels decrease. Other factors such as trauma, cuts, impactions, endocrine disorders or unknown reasons can
also cause root resorption. Usually this is of no significant consequence, but on occasion it may become a threat
to the longevity of the teeth involved.
______ Impacted Teeth When attempting to move an impacted tooth, various problems may be encountered.
These may include, but not be limited to: tooth loss, periodontal problems, relapse {slipping back to original tooth
position), and root resorption of the impacted and/or adjacent teeth requiring root canals or in rare instances
tooth removal. Anklyosis {firm attachment of the impacted tooth in the bone) may require surgical removal of the
tooth.
______ Facial Growth Patterns
Occasionally, unexpected, or abnormal, changes in the growth of the jaws or
shape and size of the teeth, may limit our ability to achieve the desired result. Unusual, insufficient or excess
skeletal growth patterns during or after orthodontic treatment can compromise dental results, facial appearance, or
cause shifting of previously aligned teeth. Additional treatment and/or surgical correction may be recommended.
Growth disharmony is beyond the orthodontist's control.
______ Habits
Uncorrected thumb sucking habits, tongue thrust habits, or mouth breathing can also prevent
successful treatment results or lead to relapse later.
______ Tooth Size Discrepancies or Missing Teeth In some cases, after the teeth are aligned and straightened,
size discrepancies {differences between the sizes of individual teeth) may exist. The space between teeth may need
to be bonded or crowned by your dentist rather than closed orthodontically. If permanent teeth are missing, they will
need to be replaced at the end of orthodontic treatment with bridges or implants. Your dentist will complete these
procedures.
______ Temporomandibular Joint (TMJ)
The TMJ is the sliding joint on either side of the lower j aw. Problems
may develop at any time period during, or following the course of orthodontic treatment. It is more common in
females in their late teens or early twenties and later forties. Many times a blow to the jaw may injure the TMJ.
Sometimes the symptoms do not show up until years after the injury. Popping, clicking, locking of the jaw, facial pain
or muscle spasms may be noticed. The emotional state of the patient has a direct influence on the TMJ. Tooth
position or bite relationship can affect the TMJ but many problems simply are not bite related. Remember, most
individuals that have a TMJ problem have never had orthodontic treatment. Orthodontic treatment may help remove
the dental causes of the Temporomandibular Disorder, but not the non-dental causes.
______ Relapse All teeth have a tendency to change their positions after treatment. This is usually only a minor
change and faithful wearing of retainers reduces this tendency.This is a lifetime commitment; patients never outgrow
the tendency for teeth to relapse. If the patient discontinues retainers, some relapse may occur. Throughout life, the
bite can change adversely due to unusual growth, the eruption of wisdom teeth, mouth breathing, and other oral
habits that are out of the control of the orthodontist.
___ Various Unusual Occurrences Swallowing or aspirating appliances, cracked or chipped teeth, dislodging
fillings or crowns (caps), rare allergic reactions or developing cysts may occur in some patients. Sometimes
orthodontic appliances and/or the adjustment of them may irritate or damage the oral tissue. People who are already
allergic to certain foods, or who have hay fever, are more prone to allergies to orthodontic materials.
_______ Treatment Schedule
Estimated and actual treatment time may differ in some patients. Excessive or
deficient bone growth, poor patient cooperation, poor oral hygiene, insufficient elastic (rubber band) wear, insufficient
headgear wear, broken appliances {braces), and missed appointments can lengthen the treatment time and affect
the quality of the result.
_______ Ceramic Brackets Ceramic brackets may inadvertently remove some of the tooth's enamel if the tooth
has enamel fracture lines or if the occlusion causes a bracket to become loose. Also, if worn on the lower teeth,
they may cause abrasion or damage to the upper teeth. Pieces of the ceramic brackets may break off and there is
a possibility that they may be swallowed or aspirated.
Informed Consent
Page 2 of 3
_______ Oral Surgery
Sometimes oral surgery or tooth removal is necessary in conjunction with orthodontic
treatment, especially to correct severe jaw imbalances. There are extremely rare, life threatening risks and
disabilities involved with anesthesia in oral surgery. You must discuss these issues with your dentist or oral
surgeon before deciding to proceed with the surgery.
_______ General Medical Problems
Please keep us informed if any medical problems should develop. These
problems could affect your orthodontic treatment
_______ lnterceptive/Phase I Treatment
If the patient is having lnterceptive or Phase I treatment at this
time, understand that additional treatment (Phase II) will be necessary later at an additional fee, once all
permanent dentition has erupted .
Possible Alternatives
_______ Orthodontic treatment is often an elective procedure. You may decide that you are willing
to accept the state of your current dental health and decide not to pursue orthodontic treatment. The
specific alternative to the orthodontic treatment of any particular patient depends on the nature of the
individual's teeth,supporting structures, and appearance.
Alternatives could include:
1. Extractions versus treatment without extractions
2. Orthognathic surgery treatment versus treatment without orthognathic surgery
3. Possible prosthetic and/or restorative solutions
4. Possible compromised approaches
5. Positioner Therapy is an option after Comprehensive/Phase II Orthodontic Treatment
Consent
We have provided this information to you to provide you with as much information as possible
about the potential risks and limitations associated with orthodontic procedures . Other inherent risks not
mentioned may also occur. As a rule, significant improvement can be achieved with orthodontic treatment
but as with any healing art, results cannot be guaranteed. Your cooperation and understanding are
sincerely appreciated as we make every effort to achieve the results we both seek.
I hereby acknowledge that the major treatment considerations and potential risks of orthodontic
treatment have been presented to me.
I have read and understand the information in this form and also understand that there may be
other problems that occur less frequently or are less severe.
Dr. Monacell has presented this information to aid in the decision-making process, and I have been
given the opportunity to ask Dr. Monacell any questions I may have about the proposed treatment, treatment
alternatives, risks and the information contained in this form.
I also understand that should any of these conditions threaten the health and well-being of the
patient, that this practice may terminate treatment.
Signature
Date
Relationship to Patient
Informed Consent
Page 3 of 3
Orthodontic Appointments
In order to ensure quality orthodontic care, it is imperative that you understand the manner in which we
schedule appointments. Our goal is to be the best part of your day. We make it a top priority to value both
you and your time. That’s why we make every effort to stay on time or ahead of schedule. Most patients
or parents work and all children attend school. Interrupting your work or your child’s studies as
infrequently as possible is very important to our entire office. Since the majority of our patients are of
school age, it is unavoidable that some school-time appointments will be necessary.
We want you to know that our team will work hard to provide the finest orthodontic care in the most
convenient scheduling system possible for you. We also have families and understand your scheduling
concerns. Our office will do everything we can to ensure that treatment goes as smoothly as possible.
•
SHORT, ROUTINE ADJUSTMENT APPOINTMENTS: These are scheduled early morning and late
afternoon.
•
LONG APPOINTMENTS, BANDING AND BONDING: These are more detailed and techniquesensitive appointments. Therefore, these appointments will be scheduled during our mid-morning and
early afternoon hours.
•
SURESMILE SCAN APPOINTMENTS: At the appropriate time in treatment, an 80-minute
appointment will be required for an intra-oral bracket scan. This appointment is time and technique
sensitive. Therefore, the appointment will need to be scheduled during early afternoon hours.
•
EMERGENCIES: (Pain, swelling, or bleeding).These patients will be seen as soon as possible.
When appropriate, a referral may be given to another specialist for emergency treatment.
•
REPAIRS: (Loose bands or brackets, broken arch wires, ties, appliances or retainers) These
appointments are scheduled during work or school hours at a specific time since they are longer
visits. The majority of appointments over the course of treatment will be short appointments.
•
MISSED OR CHANGED APPOINTMENTS: Another appointment will be scheduled but may require
waiting 4 to 8 weeks. An appointment during work or school hours may be arranged sooner.
Thank you so very much for understanding! We can always provide you with a work or school excuse for
orthodontic appointments. It is important for your child to give these to the appropriate school official.
I have read and agree to the scheduling information above:
Parent/Patient Signature:
Date:
John F. Monacell, D.D.S., P.C.
Specialist in Adult & Child Orthodontics and Dentofacial Orthopedics
1343 East Williamsburg Road • Sandston VA 23150
9448 Chamberlayne Road, Suite B • Mechanicsville VA 23116
(804) 737-6757
www.monacellorthodontics.com
(804) 746-0918