Today’s Date:
First Name:
M.I.
Last Name:
Male
Female
Date of Birth (MM/DD/ YYYY) :
Age:
Social Security #:
Address:
Apt#:
City:
State:
Zip:
Home Phone:
Cell Phone:
E-mail Address: *
Who told you about us?
General Dentist (name):
Internet
Yelp
Healthgrades
Google
Facebook
ZocDoc
Other:
I am interested in:
Braces
Invisalign
Other:
(Please circle which applies)
Mother
Father
Spouse
Self Name:
Name:
Date of Birth
Soc. Sec. #
Occupation
Where Employed
Business Phone No.
Cell Phone No.
(Please circle which applies)
Mother
Father
Spouse
Self Name:
Name:
Date of Birth
Soc. Sec. #
Occupation
Where Employed
Business Phone No.
Cell Phone No.
Marital Status:
single
married
separated
divorced
partner
Insurance (Primary)
Policy Holder’s Name
Insurance Name
ID#
Group name
Insurance Phone No.
Insurance (Secondary)
Policy Holder’s Name
Insurance Name
ID#
Group name
Insurance Phone No.
Dental History
Name of your General Dentist:
Office Phone
Address:
City:
State:
Zip:
Date of Last Visit:
Reason of Last Visit:
Have you had previous orthodontic treatment?
Y
N
If yes, please explain:
Please select Y = Yes or N = No if you have experienced any of the following:
1. Ever fainted?
Y
N
2. Had an allergic reaction?
Y
N
3. Had abnormal bleeding?
Y
N
4. Do your gums bleed on brushing or eating?
Y
N
5. Does food catch between your teeth?
Y
N
6. Have your teeth shifted?
Y
N
7. Are there spaces between your teeth now where there was none?
Y
N
8. Any other complications during or following
Y
N
Dental treatment?
9. Are your teeth flaring or are some of them loose?
Y
N
10. Are your teeth sensitive to cold, heat or pressure?
Y
N
11. Do you grind your teeth? Clench your jaws
Y
N
12. Do you have pain or clicking in the jaws around your ears?
Y
N
13. Are there any sores or growths in your mouth?
Y
N
14. Do any of your teeth ache?
Y
N
15. Any other dental complaints?
Medical History
Patient’s Name:
DOB
SS#
Name of your Physician:
Office Phone
Address:
City:
State:
Zip:
Date of Last Visit:
Reason of Last Visit:
Are you currently under the care of a physician? If yes, for what reason
Are you currently taking any medication? If yes, what medication and for what reason or conditions?
Please select Y = Yes or N = No if you have had or been treated for any of the following:
Y
N
Rheumatic Fever
Y
N
Rheumatic Heart Disease
Y
N
Heart murmur
Y
N
Congenial heart disease
Y
N
Heart trouble
Y
N
Heart attack
Y
N
Angina
Y
N
Heart surgery
Y
N
Pacemaker
Y
N
Irregular beats
Y
N
Stomach or intestinal disease
Y
N
Abnormal blood pressure
Y
N
Excessive bleeding
Y
N
Anemia
Y
N
Asthma
Y
N
Tuberculosis
Y
N
Hay fever
Y
N
Cancer
Y
N
X-Ray treatments or chemotherapy
Y
N
Diabetes
Y
N
Hepatitis Type: (circle) A, B or C
Y
N
Jaundice
Y
N
Liver disease
Y
N
Kidney disease
Y
N
Renal dialysis
Y
N
Venereal disease
Y
N
AIDS/HIV
Y
N
Stroke
Y
N
Convulsions
Y
N
Fainting spells
Y
N
Tumors or growths
Y
N
Arthritis
Y
N
Rheumatism
Medical History
Other conditions not listed of which you are aware?
For Women: Are you pregnant?
Allergic reactions to medications?
Have you ever had major operations?
Have you ever had a serious injury to the head or neck?
Yes
No
…If yes, describe
Are you on a special diet? If yes, for what reason and describe
Do you smoke? If yes, describe type and quantity:
Have you consulted or been treated by a psychiatrist, psychologist or counselor? If yes, describe:
NOTE: A change in your medical/dental status should be reported to the office at the earliest possible time
Consent:
The undersigned hereby authorizes Dr. Mizrahi to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Mizrahi to make a thorough diagnosis of the patient’s orthodontic needs.
I also authorize Dr. Mizrahi to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with (patient name)
I
understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctor choose and employ such assistance as deemed fit to provide recommended treatment.
I understand that all responsibility for payment for orthodontic services provided in this office for my dependents or myself is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1 – ½ % finance charge (18% APR) may be added to my account, in addition
to any collection charges.
Permission To Release Health Information:
I grant the right to the dentist to release health information obtained from me, and my dental treatment to third party payors, and/or health practitioners.
I understand that it is my responsibility to advise your office of any changes in the information contained on this form.
Insurance Patients:
I understand that I may be responsible for any unpaid balance from my insurance.
To the best of my knowledge, the foregoing questions have been accurately answered.
Patient or Guardian Signature
(parent/guardian must sign if patient is a minor
Date:
PRINT Name of person signing
Relationship to patient
Patient’s Name
DOB
A requirement facing all practitioners of medicine and dentistry is that the patient or the legal representative of the patient gives the practitioner informed consent. Informed consent indicates your awareness of the negative as well as the positive aspects of orthodontic treatment. This includes your understanding of the diagnosis, nature and purpose of proposed treatments, risks and consequences, treatment alternatives, and prognosis if there is no treatment.
You have my assurance that even though informed consent is legal requirement of all practitioners of medicine and dentistry I will endeavor to keep these negative possibilities of orthodontic treatment to a minimum.
Perfection may be our goal, but in dealing with problems of growth and development, genetics and environment, as well as patient cooperation, as we do in orthodontics, adequacy may be a necessary standard.
Teeth shift during the lifetime of any individual regardless of orthodontic treatment. With orthodontic treatment there are changes in the positioning of the teeth following active treatment. Some patient’s front teeth tend to become slightly irregular during the late teens following orthodontic treatment - particularly if, at the onset of treatment, they are extremely crowded. I recommend that retainers are to be worn indefinitely following active treatment to prevent relapse (teeth shifting) in future.
In certain instances the enamel of some teeth can be affected by protracted wearing of bands or bonded attachments in the presence of poor oral hygiene. This results in the decalcification or scarring of the enamel as evidenced by white or soft areas on the enamel. This can be minimized by the careful brushing of the braces and teeth as directed and the avoiding of taffy, caramel, and chewing gum which can enhance enamel dissolution.
On rare occasions the nerve of a tooth can undergo regression and may become non-vital as a consequence of pressure of orthodontic appliances or trauma to the tooth such as blows, falls, or being hit by an object.
At times a patient may have an existing periodontal condition that may prevent any possible orthodontic treatment. During orthodontic treatment it is essential that good oral hygiene be maintained as the soft tissue gums may be more prone to inflammation and infection. If this were to occur, it may be necessary to refer the patient to the dentist for treatment and if the condition persisted, it may be necessary for the braces to be removed even though orthodontic treatment has not been completed.
At times it may be necessary in individuals with constricted arches to utilize a Rapid Palatal Split appliance. The intent of this appliance is to improve the bony relationships of the upper and lower jaw and the success depends upon the patient cooperation and age. There are many times when there may be a relapse and full cooperation is not possible.
A small percentage of non-orthodontic patients show evidence of root resorption (decrease in size of root surface or root length or changes in shape) of some teeth. The incidence of root resorption is increased amongst patients undergoing orthodontic treatment and is considered a scar of treatment. Root resorption in the great majority of orthodontic patients does not jeopardize the health, function, longevity, or appearance of the tooth or teeth. In a very few patients, and the occurrence is rare and statistically insignificant, root resorption of over one-third the length of the root can occur. This substantial decrease in size of the root can cause a dental problem requiring other dental procedures, and in extreme cases can result in tooth loss. It must be remembered that this unusual decrease can occur in individuals that have never been treated by an orthodontist.
In some instances, and here again the incidence is infrequent, the patient presents at the onset or during treatment or at the conclusion of treatment some problems with the joint of the lower jaw. This is manifest by “clicking” or pain in the joint upon opening or closing of the jaws. These symptoms can also be present individuals who are not undergoing orthodontic treatment. Problems of the so-called “temporal mandibular joint” known as “temporal mandibular dysfunction” are an enigma to practitioners of dentistry and the resolution of this problem, at this time, is not assured.
I consent to the taking of photographs and x-rays before during and after treatment, and to the use of them by the doctor in scientific papers or demonstrations. I certify that I have read or have had read to me the contents of this form and do realize the risk and limitations involved, and do consent to orthodontic treatment. No practitioner of medicine or dentistry can guarantee any result but can only indicate that they will attempt to resolve the particular problem. To this end you have my assurance.
Patient or Guardian Signature
(parent/guardian must sign if patient is a minor)
Date:
Print Name of person signing
Patient’s Name
Date of Birth
PRIVACY CONSENT
This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign and date this form.
Your protected health information, (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses and demographic data) may be used in connection with your treatment, payment or your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).
You have the right to review our office’s privacy notice prior to signing this Consent Form, a copy of which you may request along with this Consent Form.
You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.
We may amend our office’s privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.
You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.
Thank you for your cooperation. Please let us know if you have any questions.
Patient or Guardian Signature
(parent/guardian must sign if patient is a minor)
Date:
PRINT Name of person signing
Relationship to patient
Patient Advisory and Acknowledgment
Receiving Dental Treatment During the COVID-19 Pandemic
Dear Patient:
You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:
While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of the COVID-19 virus, we cannot make any guarantees.
Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge.
In order to reduce the risk of spreading COVID-19, we have asked you a number of “screening” questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.
PATIENT/RESPONSIBLE PARTY
Date
PLEASE ANSWER “YES” OR “NO” WITH YOUR INITIALS, TO THE FOLLOWING QUESTIONS: .
ARE YOU CURRENTLY AWAITING THE RESULTS OF A COVID-19 TEST?
YES
NO
DO YOU HAVE A FEVER?
YES
NO
DO YOU HAVE ANY SHORTNESS OF BREATH?
YES
NO
DO YOU HAVE A DRY COUGH?
YES
NO
DO YOU HAVE A RUNNY NOSE?
YES
NO
DO YOU HAVE a SORE THROAT?
YES
NO
DO YOU HAVE SNEEZING, WATERY EYES, AND/OR SINUS PAIN/PRESSURE THAT IS UNUSUAL AND NOT RELATED TO SEASONAL ALLERGIES?
YES
NO
HAVE YOU EXPERIENCED HEADACHES, FATIGUE, OR WEAKNESS?
YES
NO
HAVE YOU LOST YOUR SENSE OF TASTE AND/OR SMELL?
YES
NO
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED TO ANY FOREIGN COUNTRY?
YES
NO
WITHIN THE LAST 14 DAYS, HAVE YOU TRAVELLED WITHIN THE UNITED STATES?
YES
NO
IF SO, WHERE?