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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