Patient Information Patient Name*
Gender Social Security Number*
Birth Date*
MM slash DD slash YYYY
Drivers License Number*
Home Address*
Primary Phone Number*
Home or Cell Phone Number* E-mail Address*
School
Employer's Name*
Occupation*
Spouse/Emergency Contact Information Marital Status* Spouse/Partner's Name
Emergency Contact Name*
Phone Number*
Relation to You*
Address*
Person(s) OK to release appointment or medically related information to concerning you.*
Relation*
Insurance Information Primary Insurance Company
Insurance Phone Number
Group Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Secondary Insurance Company
Secondary Insurance Phone Number
Group Number
Member ID Number
Policy Holder's Name
Relation
Policy Holder's Social Security Number
Policy Holder's Birth Date
MM slash DD slash YYYY
Employer
Work Phone Number
Co-pay (if known)
Deductible (if known)
Dental History General Dentist*
Last Visit*
MM slash DD slash YYYY
How did you hear about our Practice?* Name of person referring (if applicable)
What are the main concerns you would like orthodontics to accomplish?*
Have you visited an orthodontist before?* When?
Reason?
Have your tonsils or adenoids been removed?* Have you ever experienced jaw joint pain/discomfort (TMJ/TMD)?* Do you have any missing or extra permanent teeth?* Have you ever had an injury to (select all that apply): Do you have speech problems?* If so, explain:
Do your gums bleed?* Do you smoke?* Do you like your smile? Do you currently or have you ever had any of the following habits? Patient Signature and/or Responsible Party*
Date*
MM slash DD slash YYYY
Doctor Signature (OFFICE USE ONLY)
Date
MM slash DD slash YYYY
Medical History Are you currently being treated by a physician?* Reason
Physician
Phone
Do you have any allergies/sensitivities to medications or latex?* If yes, please list allergies:
Are you currently taking any prescription or over-the-counter medications?* Please list, with dosage:
Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Apidex, Fastin (brand names of Phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine)? Have you had any serious illnesses or operations?* If yes, describe:
Have you ever had a blood transfusion?* Give Approximate Dates of Blood Transfusion
Are you pregnant? Nursing? Taking birth control pills? Check if you have or have ever had any of the following: Authorization I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.
Patient Signature and/or Responsible Party*
Date*
MM slash DD slash YYYY
Doctor Signature (OFFICE USE ONLY)
Date
MM slash DD slash YYYY
Informed Consent and Risks of Orthodontic Treatment The following information is routinely provided to anyone considering orthodontic treatment in our office(s). While recognizing the benefits of a pleasing smile and healthy teeth, you should also be aware that orthodontic treatment, like any treatment of the body, has inherent risks and limitations. These potential complications, though rarely encountered, should be considered when deciding to initiate orthodontic treatment. Please note that it is impossible to list every possible circumstance, so this list is to be considered an incomplete list. Informed consent should not be given unless you understand this material completely. Please ask the Orthodontist to explain anything you do not understand. A certain amount of discomfort should be expected when braces are placed and at each adjustment appointment.
Initial - Root Resorption*
*Root Resorption* In some patients, the ends of the roots of the teeth are shortened during orthodontic treatment. Under healthy circumstances, the shortened tooth roots are no real disadvantage. However, some patients are more prone to severe episodes of root resorption, while for most the resorption is minimal. On occasion, the root shortening can reduce the longevity of affected teeth especially in the event of subsequent gum disease . It is nearly impossible to predict susceptibility to this condition.
Initial - Decalcification, Decay and Gum Disease*
*Decalcification, Decay and Gum Disease* Any one or all of these problems may occur if the patient is not cooperative with brushing, flossing, and getting regular professional cleanings/gum maintenance at their general dentist, pedodontist or periodontist. These regular checkups should be a minimum of twice a year, and at times more frequent if recommended. Proper dietary control is also essential, with special attention to the amount and frequency of sugar in the diet. With adults, we ask for increased attention to prevention of gum disease. If periodontal disease occurs during the course of treatment, it may be difficult or impossible to control the bone loss and subsequent loss of teeth.
Initial - Ankylosed Teeth*
*Ankylosed Teeth* In some instances teeth will not move because they are directly attached to the bone (ankylosed). An ankylosed tooth may need surgery to aid in its movement or it may need to be removed.
Initial - Treatment Time*
*Treatment Time* This is our best guess as to how long treatment will take to complete. Progress can be delayed by abnormal or lack of facial growth, mechanical difficulties encountered while moving teeth, poor patient cooperation, gum disease, broken appliances and missed appointments are all important factors.
Initial - Abnormal Growth/Late Growth Changes*
*Abnormal Growth/Late Growth Changes* Abnormal growth can upset even the most carefully planned treatment. A patient's growth pattern cannot be predicted perfectly. A person who has grown in an average proportion may not continue to do so. If growth becomes disproportionate, the jaw relationships may be greatly affected and original treatment objectives may not be met. This circumstance will be brought to the parent/legal guardian or patient's attention immediately following its recognition and a new treatment plan may be discussed.
Initial - Additional Treatment**
*Additional Treatment* Unforeseen circumstances (growth changes, gum disease, severe root resorption, ankylosed teeth, etc.) may cause us to recommend a form of treatment not previously discussed. If this occurs, we will carefully explain the reasons for a change in the treatment plan and any extra fee(s) before proceeding.
Initial - Return of the Original Problem*
*Return of the Original Problem* Many problems tend to return to a small degree. Especially severe problems in patients may do so. In addition, adults have a higher than normal chance of seeing some return of the original problem. We will make our corrections to the highest possible standards, and hold the result carefully. When and if retention is discontinued, we will expect some return. Careful cooperation during the retention period, and at times lifetime retention, will be required to keep this rebound to a minimum.
Initial - Severely Overlapped Teeth*
*Severely Overlapped Teeth* Severely overlapped teeth, especially on adults may have caused a loss of gum tissue between the teeth. When these teeth are straightened, the lack of gum tissue (termed "dark triangles") may become more noticeable. We will make every attempt to minimize the size of these dark triangles, but cannot guarantee complete removal.
Initial - Orthodontic Surgery Cases*
*Orthodontic Surgery Cases (Orthognathic)* As this is not an exact science and many complex factors influence the course of the treatment, it is possible in certain individual cases that orthodontic treatment and surgery (jaw modification surgery) is required at any phase during the course of the treatment. It is understood that you have the choice to decline jaw surgery, but the end result may be compromised. In extreme cases, the Orthodontist may decide it is in the patient's best interest to have jaw surgery and may discontinue the treatment if the required jaw surgery is declined.
Initial - Devitalization*
*Devitalization* It is possible for a tooth to die during orthodontic treatment, especially if it was previously injured or was impacted. Sometimes such injuries are unknown to the patient or the parent(s). Such previous injuries cannot be detected by the orthodontist. For this reason, a tooth may die and the reason for it may not be apparent. Root canal treatment may be recommended if you have such a problem. In extreme cases but rare cases, extraction may be necessary.
Initial - Phase I Treatment*
*Phase I Treatment* Phase I treatment is an early guidance or partial appliance phase on patients who have a mixture of baby (primary) and adult (permanent) teeth. The purpose of a Phase I treatment, when it is indicated, is to facilitate a better overall treatment outcome. Phase I treatment is sometimes followed by a waiting period for permanent teeth to erupt, and may or may not include temporary retainers to hold the Phase I result. Other times Phase II, or the final phase of active treatment, follows immediately after Phase I. Phase I and Phase II treatment fees are often separate. In extreme problem cases, a Prephase I treatment may be required and will occur before Phase I. Prephase treatment rarely has retention and is a separate fee.
Initial - Injury from Appliance(s)*
*Injury from Appliance(s)* Headgear and other appliance instructions must be carefully followed. A headgear that is pulled away from the teeth while the elastic force is attached could snap back into the face or eyes. Be sure to release the elastic force before removing the headgear from the teeth. On rare occasions when dental/orthodontic instruments are used in the mouth, the patient may get scratched, poked or receive a blow to a tooth with potential damage or soreness to mouth/face/eye structures. Brackets and wires can be dislodged or broken and as such can be swallowed or inhaled. The risk is increased when the patient ignores advice and recommendations. Elastics and ligatures that are loose should be pushed back into place with a pair of tweezers, bent spoon, or eraser at the end of a pencil.
Initial - Removable and or Functional Appliances*
*Removable and or Functional Appliances* These appliances are sometimes used to help with the tooth and jaw alignment process. Most critical to their success is patient cooperation, and care not to damage or distort the appliance. If the appliance is removable, it must accompany the patient to each adjustment appointment.
Initial - Appointment Intervals*
*Appointment Intervals* Appointment intervals are planned carefully, and vary depending on the stage of the patient's treatment and the appliances used. The Orthodontist depends on proper cooperation between appointments, and upon the appliance remaining intact. If there are any problems between visits, please call the office as soon as possible. In addition, missed appointments, by the time they are rescheduled, can cause longer treatment time.
Initial - TMJ Pain*
*TMJ Pain* Some patients are very sensitive to even a slight discrepancy in their bite. These patients may suffer from noise or pain in the joint of the lower jaw (near the ear). This may occur before, during, or after orthodontic treatment. It also happens to people who have never had orthodontic treatment. The current belief is that stress, habitual grinding/clinching of teeth, muscle disorders, referred pain, and a host of other potential habits/problems are linked to TMJ pain. Orthodontics does not cause TMJ pain, but on some occasions it may improve the condition. However, we cannot guarantee TMJ pain will be corrected with orthodontic treatment, and treatment with another specialist may be required.
Initial - Ceramic/Metal Brackets*
*Ceramic/Metal Brackets* There have been some reported incidents of patients experiencing bracket breakage and/or damage to teeth. If brackets fracture outside of the office, it may result in sharp edges might be harmful to the patient. Also, these brackets may cause enamel flaking and/or enamel fracturing on band removal. If these brackets are worn on the bottom teeth, they may wear the enamel of the upper teeth.
Initial - Impacted Teeth*
*Impacted Teeth* Impacted teeth stay partially or completely under the gum due to either from lack of room to erupt or for no apparent reason. Wisdom teeth are the most commonly impacted teeth and may need to be removed. Other impacted teeth may need to be uncovered by an oral surgeon or periodontist and have attachments glued or bonded to them to assist the in their movement. Occasionally the surgical process needs to be repeated if the bonded attachment comes loose or if the tooth becomes stuck to the bone (ankylosed). Not all impacted teeth can be moved into the mouth successfully, which may necessitate their removal.
Initial - Removal of Teeth*
*Removal of Teeth* Sometimes teeth must be extracted as part of the orthodontic treatment. This will be based on the orthodontist's judgment of the case. In some instances, treatment may be started without extractions initially but they may be required later in treatment if a satisfactory result cannot be achieved. Extractions are NOT included in the orthodontic treatment fee.
Initial - Success of Treatment*
*Success of Treatment* We intend to do everything possible to provide the best result in every case, and it is our opinion that the treatment will beneficial. However, we cannot guarantee that the proposed treatment will be successful or to your complete satisfaction. Due to patient differences, there exists a small possibility of failure, relapse, or selective retreatment, despite the best of care. Much of the success of treatment depends on the understanding and cooperation of the patient.
Initial - Pre-existing Crowns/Caps*
*Pre-existing Crowns/Caps* In extreme cases, existing caps/crowns on teeth may become loose and need recementation by your general dentist. You understand this is your responsibility as we cannot predict when or if this can occur during orthodontic treatment. Also, caps/crowns were fit to the patient's existing bite which will be changed with orthodontic treatment. Therefore, there are occasions when you may need a new cap/crown during or after orthodontic treatment. Any recementation or new cap/crown is NOT included in the orthodontic fee.
We are confident that most of these items can be resolved or completely avoided if instructions are followed accordingly.
INFORMED CONSENT AND TREATMENT AUTHORIZATION As the patient or the patient's parent or legal guardian, I have read and understood, the above and had all my questions answered to my complete satisfaction and do hereby give my consent for the initiation of orthodontic treatment by the doctors and staff at Cain Orthodontics. Furthermore, I am aware that orthodontic records, including photographs, may be utilized for the purpose of professional consultation, research, education or publication within professional journals, without my prior notification and without additional consent or compensation.
Patient or Parent Signature
Date
MM slash DD slash YYYY
Signature of Patient's Legal Guardian (if applicable)
Date
MM slash DD slash YYYY
Witness (employees only)
Date
MM slash DD slash YYYY
Doctor Signature (OFFICE USE ONLY)
Date
MM slash DD slash YYYY
Assignment of Insurance Benefits Initials - Insurance Benefit*
I acknowledge that I am the subscriber/spouse of subscriber and request that insurance benefit paymentsbe made directly to Cain Orthodontics, PC for treatment rendered in their office for myself and/or mydependents.
Initials - Release Insurance Company*
I authorize Cain Orthodontics, P.C. to release to the insurance company and its agents any information about me or my dependants needed to determine these benefits or the benefits payable to related services.
Initials - Medical Information Release*
I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim.
Initials - Charges*
I understand that I am financially responsible for all charges payable to Cain Orthodontics, P.C. not paid by said insurance.
Printed Name of Insured*
Relationship to Patient*
Signature of Insured*
Date*
MM slash DD slash YYYY
Financial Policy Thank you for choosing our office for your orthodontic treatment. We realize that every person's financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the orthodontic care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. Orthodontic treatment is an excellent investment in an idividual's medical and psychological well-being. We are always available to answer your questions or assist you in any way we can.
Agreement To Pay For Treatment
The patient and responsible party listed below hereby agree to pay all charges submitted by the office during the course of treatment for the patient. If the patient has insurance coverage with a managed care organization with whom this office has contractual agreement, the patient and/or responsible party agree to pay all applicable copayments and deductibles (please review our financial policy below) which arise during the course of treatment for the patient. The patient and/or responsible party also agree to pay for the treatment rendered even if the treatment is not considered to be a covered service by a third party insurance company.I (patient and/or responsible party) realize that the failure to keep this account current may result in dismissal from the practice and my being unable to receive additional services except for emergencies or when there is a prepayment for additional services. In the case of default on payment of this account, I (patient and/or responsible party) agree to pay collection incurred in attempting to collect on this amount or any future outstanding balances.
Financial Policy
Payment is due on the day services are rendered, unless prior financial arrangements have been made with our office manager. We will submit your dental insurance at no extra charge to you, and we expect to pay your portion of the bill on the day of service. If insurance reimbursement is not received at our office or your claim is denied, you will be billed the balance due.
My method of payment will be Broken Appointments
This time that has been reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least a 24 hour notice.
Patient signature (or parent if minor)
Date
MM slash DD slash YYYY
*IMPORTANT MEDICAL ALERT* A connection between Fosamax and other bisphosphonates, with a serious bone disease called Bisphosphonate Related Osteonecrosis of the Jaw (ONJ) has been found. The research is inconclusive on exactly how bisphosphonates affect ONJ and how frequently the condition is found. Bisphosphonates are commonly used in tablet form to prevent and treat osteoporosis in post-menopausal women. They are also used in the treatment of Paget's Disease. Stronger forms given orally or intravenously (IV) are commonly used in the management of advanced cancers including, lung cancer, breast cancer, prostate cancer, multiple myeloma and other metastatic cancers.
Have you ever taken any of the following bisphosphonates? (oral medications)
Alendronate (Fosamax) Merck and Co.* Alendronate (Fosamax Plus D) Merck and Co.* Ibandronate (Boniva) Roche Laboratories* Risedronate (Actonel) Proctor & Gamble* Tiludronate (Boniva) Sanofi Pharmaceuticals* Etidronate (Didronel) Proctor & Gamble* Have you ever been treated for cancer with chemo therapy in the past?
Pamidronate (Aredia) Novartis* Zoledronate (Zometa) Novartis* Clondronate (Bonefos) Sherling AG* If yes, when?
Prescribing Doctor
Phone
Signature
Print Name
Date
MM slash DD slash YYYY
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