Patient s SSN: Patient s Birth Date: / / SSN: Resp. Party s Birth Date: / / Marital Status: Married Single Divorced

Transcription

1 Health History Form Patient Information Patient s Preferred Name: Patient s SSN: Patient s Birth Date: / / Patient s Sex: Male Female Patient s Age: Responsible Party 1 First Name: Last Name: SSN: Resp. Party s Birth Date: / / Address: City, State, Zip: Country: Marital Status: Married Single Divorced Relationship to Patient: Self Parent/Guardian Other Home Phone: Work Phone: Cell Phone: Responsible Party 2 First Name: Last Name: SSN: Resp. Party s Birth Date: / / Address: City, State, Zip: Country: Marital Status: Married Single Divorced Relationship to Patient: Self Parent/Guardian Other Home Phone: Work Phone: Cell Phone:

2 Health History Form Primary Insurance Refer to the information on the front and back of your insurance card, and fill out the section below. Dental Insurance Company Name: Subscriber s Name: Subscriber s Birth Date: / / Insurance Company Ph #: Insurance ID #: Insurance Group #: Employer: Secondary Insurance Refer to the information on the front and back of your insurance card, and fill out the section below. Dental Insurance Company Name: Subscriber s Name: Subscriber s Birth Date: / / Insurance Company Ph #: Insurance ID #: Insurance Group #: Employer: Tertiary Insurance Refer to the information on the front and back of your insurance card, and fill out the section below. Dental Insurance Company Name: Subscriber s Name: Subscriber s Birth Date: / / Insurance Company Ph #: Insurance ID #: Insurance Group #: Employer:

3 Health History Form General Information Dentist Name: Is there pending treatment? Yes No If yes, please explain: Satisfaction of current smile: Extremely Satisfied Very Somewhat Not Very Not at all Please check all that apply: Latex Allergy Diabetes Tuberculosis Pregnant Cancer Rheumatic Fever HIV Positive/AIDS Hepatitis A, B, or C Heart Murmur Congenital Heart Defect Convulsions/Epilepsy Abnormal Bleeding Hearing Impaired Asthma Kidney/Liver Problems Handicaps/Disabilities Allergies to any Drugs Metal Allergies Jaw Clicking Finger Sucking Scarlet Fever Hemophilia Smoking/Tobacco None Please list current medications: Please list any drug allergies:

4 Health History Form Have you ever taken any medications for osteoporosis? Yes No Please explain any of the above or list any special needs or concerns: What questions would you like answered at your consultation? Referral Information Whom may we thank for referring you to our office? Family Member/Sibling Friends/Co-workers Internet: Community Event School Presentation Office Contest (Facebook, etc.) Building Sign Google Direct Mail Phone book Smile Doctor Car Sticker Smile Doctors Snow Cone Truck Smile Doctors T-Shirt Dentist referred you:

5 Successful orthodontic treatment is a partnership between the orthodontist, the team, and the patient. While the doctor and the team are dedicated to achieving the best possible outcome, an informed and cooperative patient can also help bring about positive treatment results. The patient should be aware that, along with the benefits of a healthy smile, orthodontic treatment also presents limitations and potential risks. Although these are rarely serious enough to forgo treatment, the patient should always consider alternatives, which can include prosthetic solutions or limited treatment, and should discuss all options with their doctor prior to beginning the process. RISKS AND LIMITATIONS OF ORTHODONTIC TREATMENT Additional Treatment: Growth changes, periodontal inflammation, gingival recession, and tooth or jaw discomfort can be unpredictable. The patient will be consulted if further treatment and associated fees are required. Injury From Appliances: Although orthodontic appliances are designed for maximum strength, injuries may still occur and should be immediately reported to the orthodontist. Unexpected Growth Changes: Facial structure and tooth eruption can be unpredictable and may affect the jaw relationship if they occur disproportionately. Changes following treatment may require further attention or possible surgery. Tooth Decay, Stains, and Decalcification: Plaque bacteria can damage teeth and cause permanent decalcification (white scars) or decay if not removed. Patients should brush after every meal, floss once a day, and minimize sugar intake (especially soda) while in treatment. Unexpected Tooth Eruption: Erupting teeth can become impacted or ankylosed (fused to the bone and unremovable), and may require treatment changes or possible tooth extraction. The orthodontist will monitor the patient s bone growth, including tooth formation and eruption. Inflammation or Recession of the Soft Tissues: Orthodontic appliances can irritate soft tissue in the mouth; however, this usually heals quickly. Lack of proper oral hygiene may cause gum tissue inflammation or other severe reactions that could require referral to a periodontal specialist. Pain or Discomfort in the Jaw Joint: Pain or discomfort, including clicking or popping sensations, may occur in or around the jaw joint and could require evaluation or treatment by another doctor or healthcare professional. The orthodontist should be immediately informed if this arises. Enamel Fractures: Fracture lines and undetected defects can appear in tooth enamel when placing, adjusting, or removing an appliance. They might also occur when brackets are bitten at the wrong angle, enamel is weakened by decay, or if teeth grind or rub against the appliance. Restoration may be necessary in these cases. Root Resorption: Unerupting teeth, or orthodontic forces affecting tissue surrounding tooth roots, can lead to resorption (root damage). Resorption may require a referral for exposure if it is severe. Significant damage can also

6 cause permanent tooth loss; however, this is unpredictable and rare, and progressive radiographs are taken to monitor root position. Loss of Tooth Vitality: Previous tooth, face, or jaw injuries are not always detectable, and injured teeth can turn dark or become non-vital during treatment. Braces do not cause this; however, if extreme cases arise, they may require tooth extraction or root canal treatment. Wisdom Teeth: Tooth alignment can change as third molars (wisdom teeth) erupt. Wearing retainers consistently can help minimize these effects; however, the dentist should monitor to determine if, or when, tooth extraction becomes necessary. Stability of the Result: Teeth and jaw structures constantly change, and tooth positions do not stabilize perfectly even after treatment. Wearing a retainer can help minimize these effects; however, teeth will slowly change position, and some problems may re-occur if a retainer is not worn consistently. Occlusal/Enamel Adjustment: Manicuring teeth by altering their shape, or removing enamel to flatten their surface, may be necessary to prevent a relapse or to produce the best functional and esthetic results. This will not increase the risk of decay. Periodontal Disease: Periodontal (gum and bone) disease is most often caused by poor oral hygiene and could result in treatment ending prematurely if the resulting problems cannot be controlled. The patient s oral health must be monitored by the Primary Care dentist or periodontist every 3-6 months. Smoking: Smoking increases the risk of gum disease. It also delays tooth movement and may lead to tooth loss if a compromised periodontal condition exists during treatment. Quitting smoking is strongly recommended. Allergies: It may become necessary to medically manage symptoms if the patient is allergic to materials in the appliance, such as latex rubber bands or nickel contained in braces. Although uncommon, this could result in treatment plan changes or the discontinuation of treatment all together. General Health Problems: Bone, blood, and endocrine disorders can affect treatment, as can many prescription and non-prescription drugs. Treatment may cause a temporary increase in salivation or mouth dryness, and certain medications can increase this effect. Temporary Anchorage Devices: Temporary anchorage devices (such as metal screws or plates) may be used during treatment and carry specific risks. Screws can loosen, break, or get swallowed and require removal, relocation, or replacement. Surgery may be necessary in some cases. Damage to teeth roots or nerves can occur when inserting a device, including perforation of the maxillary sinus. Devices can also cause inflammation or infection to the surrounding tissue, or soft tissue may grow over the device. This could require removing the device, surgically excising the tissue, and/or the using antibiotics or antimicrobial rinses. Usually problems involving devices are not significant; however additional treatment may be necessary. Applying or removing a device may also require the use of local anesthetics, which also carry risks. The doctor should be advised about any past difficulties with dental anesthetics before the device is applied.

7 Existing Dental Restorations: Existing dental restorations (such as crowns) may dislodge and require re-cementation, or in some instances, replacement. Treatment may not be effective for the movement of dental implants. Soft Tissue Laser: Lasers may be used to remove excessive soft tissue surrounding teeth to help facilitate or expedite treatment. Orthodontic Appliances: Orthodontic appliances, or their parts, may accidentally be swallowed or aspirated. Speech: Certain treatments or products, such as Invisalign, can temporarily affect speech or result in a lisp. These speech impediments should be temporary. ADDITIONAL CHARGES: Appliances should last throughout the treatment. However, if appliances need to be replaced or repaired due to loss, breakage, misuse, or patient carelessness, additional charges may be assessed. The treatment fee does not include general dentist care such as cleanings, restorations, fillings, crowns, checkups, extractions, exposures, implants, temporary anchorage devices, periodontal care, oral surgery, or TMJ treatment. Fees resulting from orthodontic services rendered by another provider are the sole responsibility of the patient and/or responsible party. Patient Responsibilities: Treatment will not succeed completely unless the patient complies with the orthodontist s instructions, including treatment forces requiring patient application outside the office. Correct use of Appliances: Appliances are designed to deliver forces in a specific manner, and if they are not worn as instructed, treatment will not proceed as planned. Care of Appliances: A lost, broken, or bent appliance will disrupt treatment and may result in unwanted tooth movement. The patient should notify the office immediately if their appliance becomes lost or damaged. Auxiliary Appliances: The patient may be asked to wear elastics (rubber bands) or other auxiliaries during treatment to enhance tooth movement. Treatment will not proceed as planned if these are not worn as instructed. Regularly Scheduled Appointments: Appliances must be periodically adjusted and treatment progress must be monitored carefully. Missed or rescheduled appointments will inevitably prolong treatment. Meticulous Oral Hygiene: Poor oral hygiene causes gum inflammation, decalcification (white scars on the teeth), and decay. Inflamed gum tissue slows tooth movement and prolongs treatment. The patient must brush thoroughly three times a day and floss completely once a day. Routine Dental Visits: The American Dental Association and our practice recommend that patients continue to see their dentist for regular checkups and cleanings every six months.

8 ACKNOWLEDGEMENT AND CONSENT TO TREATMENT: I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. I understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with the undersigned orthodontist(s) and have been given the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize the orthodontist(s) indicated below to provide the treatment. I also authorize the orthodontist(s) to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment. I hereby consent to the making of diagnostic records, including x-rays, before, during, and following orthodontic treatment, and to the undersigned orthodontist(s), where appropriate, team providing orthodontic treatment prescribed by the doctor(s) for the below individual. I fully understand all of the risks associated with the treatment. Patient s Name Signature of Patient/Parent/Guardian Date Signature of Orthodontist/Group Name Date

9 AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION AND USE OF RECORDS: I hereby authorize the above orthodontist(s) to disclose information regarding the above individual s orthodontic care as deemed appropriate in accordance with applicable state and federal law. I understand that once released, the above doctor(s) and team has (have) no responsibility for any further release by the individual receiving this information. Additionally, I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals. Signature of Patient/Parent/Guardian Date

10 Photography and Information Consent Form I hereby give my permission to Smile Doctors to release my orthodontic records to a referred specialist or subsequent treatment dentist or orthodontist. Smile Doctors may also utilize my records, photos and video recordings for the purposes of professional consultations, research, education, lectures, and publications in professional journals, marketing, social media sites or use on our website. Responsible party: Date: