Patient Information
Is the patient a minor?
*
Yes, the patient is a minor
No, the patient is not a minor
Patient Name
*
Birthdate
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
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29
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31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
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1958
1957
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1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Preferred Name
Gender
*
Male
Female
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
*
Home Phone
Cell Phone
*
School
*
Grade
*
K
1
2
3
4
5
6
7
8
9
10
11
12
Interests
Parent / Guardian's Name
*
Names of any friends or relatives in our practice
Name of siblings and their ages
Sibling
Age
Whom may we thank for referring you to our practice? (check any/all that apply)
Dentist
Google
Website
Friend
Family
Other
Name of friend who referred you
*
Name of family member who referred you
*
Name of referral
*
Patient's chief orthodontic concern?
*
Who will be responsible for making appointments?
*
Their phone number?
*
Parent / Guardian email
*
Patient email
*
Responsible Party Information
Responsible Party / Insured
*
Relationship to patient
*
Same address as patient
Street Address
*
City
*
State
*
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
*
Home Phone
Cell Phone
*
SSN
*
Birthdate of Responsible Party
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Work Phone
Employer
*
Occupation
*
Spouse's Name (if applicable)
Spouse's Cell Phone
Spouse's Work Phone
Other parent, if applicable
Relationship to patient
Same address as patient
Street Address
City
State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP
Home Phone
Work Phone
SSN
Employer
Occupation
Insurance Information
Do you have dental insurance?
*
If yes, please fax the front and back of your insurance card to (904) 270-8755
Yes
No
Do you have orthodontic coverage?
*
If yes, please fax the front and back of your insurance card to (904) 270-8755
Yes
No
Dental Information
Dentist
*
Date of last cleaning and exam
*
Date Format: MM slash DD slash YYYY
General Dental Health
*
Good
Fair
Poor
History of TMJ Problems
*
Yes
No
Comments on dental history (trauma, extractions, etc.)
Oral habits?
Did your dentist recommend an orthodontic exam?
*
Yes
No
Previous orthodontic treatment?
*
Yes
No
Date started?
*
Date Format: MM slash DD slash YYYY
Months remaining?
*
Orthodonist
*
Orthodonist location
*
Medical Information
Physician's name
*
Date of last physical exam
*
Date Format: MM slash DD slash YYYY
Does the patient take any medications regularly?
*
Does the patient take Fosamax or other bisphosphonate medications (typically for osteoporosis)?
*
Yes
No
Is the patient allergic to any medications?
*
Is the patient allergic to latex?
*
Yes
No
Is the patient pregnant?
*
Yes
No
Due date?
*
Month
1
2
3
4
5
6
7
8
9
10
11
12
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Overall health?
*
Good
Fair
Poor
Check any of the following that applies to the patient
Heart problems
Rheumatic fever
Heart murmur
Abnormal bleeding
Artificial heart valves
Cancer
Developmental disabilities
Blood transfusion
Difficulty breathing
HIB
Epilepsy
Diabetes
Hepatitis
Asthma
Hearing impairment
High blood pressure
Radiation treatment
Fainting
Does the patient have a history of any medical or other problems that we should be aware of?
In case of an emergency, who can we contact?
*
Their phone number?
*
NOTICE OF PRIVACY PRACTICES
We are dedicated to protecting your personal medical information and maintaining appropriate safeguards as required by law, including the Health Insurance Portability and Accountability Act (HIPAA). You are entitled to review our complete Privacy Notice which describes how we may use and disclose your medical records while you are receiving care at Lazzara Orthodontics. A notice describing our privacy practices is posted in the office, and a laminated copy is available at the front desk. We will also be happy to provide you with a copy.
Signature of patient or legal guardian
*
INFORMED CONSENT AGREEMENT
Orthodontic treatment is not an exact science. Much of its success depends on the cooperation we receive from our patients. While the benefits of a pleasing smile and good jaw function are obvious, you should be aware that orthodontic treatment has some associated hazards, inconveniences, and limitations. These draw- backs seldom outweigh the long-range benefits, but should be considered in making the decision to wear orthodontic appliances. The following information is routinely supplied to anyone considering orthodontic treatment in our office. Please read through this form carefully and ask Dr. Lazzara and/or his staff to explain anything you do not understand. It is important that you fully understand what is expected of you as a patient, or as a parent of a young patient, to achieve excellent results. Perfection is always our goal. Dr. Lazzara will use his knowledge, training, skill, and experience to attempt to achieve perfect function that is also aesthetically pleasing. However, the duration of treatment and final treat- ment result can be significantly affected by the patient’s growth, genetics, oral health, and cooperation. Restorative treatment (bonding, crowns, etc.) from your dentist may be required to achieve acceptable results in some cases. Throughout life, teeth are subject to changes in position. This is true with everyone, regardless of whether they have worn braces or not. After orthodontic treatment, patients are subject to the same changes that occur in non-orthodontic patients. Indefinite retainer wear is ABSOLUTELY MANDATORY to maintain the alignment of your teeth. One night per week is usually sufficient, but some people require more frequent wear. If additional retainers or orthodontic treatment are required to correct the consequences of poor retainer cooperation, addi- tional fees will be assessed. Orthodontic appliances do not cause cavities. However, they may trap food debris and predispose patients to the development of cavities or decalcification marks. Decalcification (permanent marks on the teeth), tooth decay, or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Patients are able to prevent these problems with a combination of proper diet, good tooth brushing habits, and regular checkups with the family dentist. It is imperative that all patients see their dentist before braces are placed, and every six months thereafter for cleaning and check-ups. Patients with a history of periodontal disease or poor oral hygiene may require more frequent visits to their dentist. Sugars and between-meal snacks should be reduced or eliminated. Occasionally, periodontal (gum) problems present before orthodontic treatment may be worsened by wearing braces and may require treatment by another specialist. Orthodontic appliances including braces, wires, elastics, headgear, retainers, and functional or other appliances can occasionally cause canker sores, irritation, or injuries to the teeth, jaw, gums, lips or other tissues. Our staff will provide you with wax to cover the area until you can visit our office. Broken braces or other appliances may rarely be swallowed or aspirated into the lungs. In such cases, a screening x-ray from your physician may be required. Allergic reactions to orthodontic appliances or materials are rare, but do occur occasionally. Mild or moderate discomfort or “sore teeth” should be expected occasionally during orthodontic treatment, espe- cially after the initial placement of braces or when appliances are reactivated. This discomfort can typically be treated with over-the-counter medications. If discomfort becomes severe, or persists beyond a few days, please contact our office immediately. Patients participating in organized sports and other rigorous activites must use a protective mouthgrad, which can obtained from our office.
Extraction of teeth, or other surgical procedures including orthognathic (jaw) surgery, are sometimes required for successful orthodontic treatment. Your family dentist, oral surgeon, or other specialist will perform any required surgery or extractions. You should discuss and understand the risks associated with extractions, surgery, or other dental procedures with your dentist, oral surgeon, or other specialist prior to those procedures. There may also be a need for fillings, crowns, bridges, gum treatment or other dental procedures before, during or after orthodontic treatment. On rare occasions the nerve of a tooth may become damaged or abscessed. A tooth that has been irritated by a deep filling or even a minor blow may require treatment by another dentist. In some instances, the roots of teeth become shortened during treatment. The process is called root resorption. The causes of the root resorption are not well understood, and it sometimes occurs even in patients not under- going orthodontic treatment. Under healthy circumstances, the shortened roots rarely cause problems. In rare circumstances, severe root resorption can result in tooth loss. Unfortunately, it is impossible to predict which patients will experience root resorption, and nothing can be done to reverse it. When patients experience root resorption, orthodontic treatment is sometimes terminated early. Orthodontic appliances are typically removed from the teeth without difficulty. However, on rare occasions, removal of appliances, particularly esthetic “clear” braces, can result in damage to the teeth or tooth enamel. There is also a small chance pain may develop in the jaw joints, i.e. TMJ’s, during orthodontic treatment. Tooth alignment or bite correction can usually improve tooth-related causes of jaw discomfort, but referral to a TMJ specialist may be required if TMJ problems occur during treatment. Occasionally, growth may become unbalanced in individuals who previously grew normally. If growth becomes unbalanced, jaw position can be affected and original treatment objectives may have to be compromised. Skeletal growth disharmony is a biological process beyond Dr. Lazzara’s control. This disharmony may necessi-tate surgical correction in conjunction with orthodontic treatment. Orthodontic treatment can only be successful if all parties are willing and able to cooperate by wearing head- gear, elastics, and retainers as instructed. Lack of cooperation will lead to increased treatment time and/or compromised results. Dr. Lazzara occasionally uses Temporary Anchorage Devices (TADS) to facilitate treatment mechanics and enhance treatment outcomes. While complications are rare, placement of TADS can result in damage to teeth or tooth roots, or the periodontal ligament surrounding tooth roots. Infection or tissue overgrowth over TADS are also possible. In rare cases, nerve damage, including altered sensation or loss of sensation may occur. Routine dental local anesthetic is used when placing TAD. If you have a heart condition, or have experienced a reaction to anesthetics in the past, please inform Dr. Lazzara. We appreciate your confidence in selecting our office. We want you to be fully informed, so please ask ques- tions anytime. During orthodontic treatment, we may make models, x-rays, and photographs which may be used for professional reference and display, orthodontic journals, books, meetings, demonstrations, and patient education.The following information is routinely supplied to anyone considering orthodontic treatment in our office. Please read through this form carefully and ask Dr. Lazzara and/or his staff to explain anything you do not understand. It is important that you fully understand what is expected of you as a patient, or as a parent of a young patient, to achieve excellent results. Perfection is always our goal. Dr. Lazzara will use his knowledge, training, skill, and experience to attempt to achieve perfect function that is also aesthetically pleasing. However, the duration of treatment and final treat- ment result can be significantly affected by the patient’s growth, genetics, oral health, and cooperation. Restorative treatment (bonding, crowns, etc.) from your dentist may be required to achieve acceptable results in some cases. Throughout life, teeth are subject to changes in position. This is true with everyone, regardless of whether they have worn braces or not. After orthodontic treatment, patients are subject to the same changes that occur in non-orthodontic patients. Indefinite retainer wear is ABSOLUTELY MANDATORY to maintain the alignment of your teeth. One night per week is usually sufficient, but some people require more frequent wear. If additional retainers or orthodontic treatment are required to correct the consequences of poor retainer cooperation, addi- tional fees will be assessed. Orthodontic appliances do not cause cavities. However, they may trap food debris and predispose patients to the development of cavities or decalcification marks. Decalcification (permanent marks on the teeth), tooth decay, or gum disease can occur if patients do not brush and floss their teeth properly and thoroughly. Patients are able to prevent these problems with a combination of proper diet, good tooth brushing habits, and regular checkups with the family dentist. It is imperative that all patients see their dentist before braces are placed, and every six months thereafter for cleaning and check-ups. Patients with a history of periodontal disease or poor oral hygiene may require more frequent visits to their dentist. Sugars and between-meal snacks should be reduced or eliminated. Occasionally, periodontal (gum) problems present before orthodontic treatment may be worsened by wearing braces and may require treatment by another specialist. Orthodontic appliances including braces, wires, elastics, headgear, retainers, and functional or other appliances can occasionally cause canker sores, irritation, or injuries to the teeth, jaw, gums, lips or other tissues. Our staff will provide you with wax to cover the area until you can visit our office. Broken braces or other appliances may rarely be swallowed or aspirated into the lungs. In such cases, a screening x-ray from your physician may be required. Allergic reactions to orthodontic appliances or materials are rare, but do occur occasionally. Mild or moderate discomfort or “sore teeth” should be expected occasionally during orthodontic treatment, espe- cially after the initial placement of braces or when appliances are reactivated. This discomfort can typically be treated with over-the-counter medications. If discomfort becomes severe, or persists beyond a few days, please contact our office immediately. Patients participating in organized sports and other rigorous activites must use a protective mouthgrad, which can obtained from our office.
I have fully read and understand this letter of information. I have had the opportunity to ask questions, and with this knowledge, I consent to treatment.
*
Check here if you consent to treatment
If the person filling this application out is not the patient, please describe your relationship to the patient
Phone
This field is for validation purposes and should be left unchanged.