Lazzara Orthodontics – Secure Forms Host

Patient Information

Is the patient a minor?*

Yes, the patient is a minor
No, the patient is not a minor

Patient Name*

Birthdate*

Preferred Name

Gender*

Male
Female

Street Address*

City*

State*

ZIP*

Home Phone

Cell Phone*

School*

Grade*

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)

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*

ZIP*

Home Phone

Cell Phone*

SSN*

Birthdate of Responsible Party*

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

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*

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?*

Months remaining?*

Orthodonist*

Orthodonist location*

Medical Information

Physician's name*

Date of last physical exam*

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?*

Overall health?*

Good
Fair
Poor

Check any of the following that applies to the patient

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

Name

This field is for validation purposes and should be left unchanged.