*First Name:
Middle Initial:
*Last Name:
Nickname:
*Birthdate:
*Gender:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Social Security #:

Please list the names of any friends or family currently in the practice:
List any sports, hobbies, or musical instruments played:
Whom may we thank for referring you to our practice?
*First Name:
Middle Initial:
*Last Name:
*Birthdate:
Relationship to Patient:
Social Security #:
*Address:
*City:
*State:
*Zip:
*Main Phone:
2nd/Cell Phone:
Email:
Employer:
Occupation:
Length of Employment:
Work Phone #:
Do you have insurance that covers orthodontics?
If so, please name the Insurance Company below:
Insurance Policyholder's Name:
Policyholder's Social Security #:
Policyholder's Date of Birth:
Insurance Group Number:
Insurance Member ID (or KMAP) Number:
Dentist Name:
Check-up Frequency:
Last Dental Visit:
Has the patient had an orthodontic consultant or treatment?
If so, when?
What is the patients main orthodontic concern?
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Speech problems/therapy?
Grind or clench teeth?
Oral habits (thumb/finger sucking, lip/nail biting)?
Injury to face, jaw, teeth or mouth?
Discomfort from teeth or gums?
Pain, tenderness or noise in either jaw?
Frequent headaches?
Neck/shoulder pain?
Frequent sore throats?
Brush teeth daily?
Floss teeth daily?
Fluoride treatments?
Mouth breathing?
Snores during sleep?
Requires premedication?
Any missing or extra permanent teeth?
Apprehensive about dental care?
Frequently Chew Gum?
If any of the above dental questions were answered 'Yes', please explain:
Physician Name:
Date of last Physical:
Patient Health:
Address:
City:
State:
Zip:
List any medications currently being taken by the patient:
List any drug allergies or sensitivities that the patient may have:
Please select YES if the patient has had any of the conditions listed below either now or in the past. Cannot be blank.
Rheumatic Fever
Tuberculosis/Lung Disease
Pneumonia
Liver Disease
Kidney Disease
Heart Attack/Stroke
Heart Disease
Congenital Heart Defect
Heart Murmur
Hemophilia
Hypertension/High Blood Pressure
Prolonged Bleeding/Transfusion
Anemia
HIV/AIDS
Hepatitis
Tonsils/Adenoids Removed
Cancer
Family History of Cancer
Received Radiation Treatment
Growth Problems
Endocrine Problems
Hormone Therapy
Latex/Metal Allergy
Nervous Disorders
Bone Disorders/Bone Loss
Diabetes
Seizures/Epilepsy
Handicaps/Disabilities
Asthma
Arthritis
History of Nicotine, Alcohol Use, or Substance Abuse
Treated for Emotional Problems
Ever Been Hospitalized
Have you taken in the past or are you currently taking any Bisphosphonates or similar medications?
If any of the above medical questions were answered 'Yes' , please explain:
If patient is under the age of 18, please answer the following questions:
Please list the name and birthdate of any siblings:
Height:
Weight:
School:
Grade:
Father/Guardian 1 Name:
Mother/Guardian 2 Name:
Has patient begun puberty:
If patient is a girl, has menstruation begun:
If patient is a boy, has their voice changed or have facial hair:
Has the patient grown in the past year or has their shoe size changed recently:
Patient's interest in treatment:
Has either biological parent ever had orthodontic treatment:
LETTER OF INFORMATION AND CONSENT AGREEMENT
for
ORTHODONTICS:    An exciting treatment that can provide:
  • Better health and comfort
  • Improved appearance
  • Enhanced self esteem
As a rule, excellent orthodontic results will be achieved by well-informed and cooperative patients. The following information is routinely supplied to all who consider orthodontic treatment. While recognizing the benefits of healthy teeth and a pleasing smile, you should also be aware that orthodontic treatment has limitations and potential risks. These are seldom enough to avoid treatment, but should be considered in making the decision to undergo orthodontic treatment. Orthodontic treatment usually proceeds as planned; however, like all areas of the healing arts, results cannot be guaranteed. Regular visits to your family dentist during treatment are a must!
BENEFITS
Orthodontics plays an important role in improving overall oral health, and in achieving harmony between the teeth and face for a beautiful, healthy smile. An attractive smile enhances self esteem, which may actually improve the quality of life itself. Properly aligned teeth are easier to brush, and thereby may decrease the tendency to decay, or to develop diseases of the gum and supporting bone.
NATURE AND PURPOSE OF THE PROCEDURES
Orthodontics improves the bite by properly directing the forces placed on teeth. Orthodontic treatment distributes the chewing stress throughout the mouth to minimize excessive stress on bones, roots, gum tissue and temporomandibular joints. Through orthodontic treatment, potential dental problems may be eliminated, including the problem of abnormal wear. Treatment can facilitate good oral hygiene to minimize decay and future periodontal problems. Also, orthodontics can provide a pleasant smile, which can enhance one's self-image.
RISKS
All forms of medical and dental treatment, including orthodontics, have some risks and limitations. Fortunately, in orthodontics complications are infrequent and when they do occur they are usually of minor consequence. Nevertheless, they should be considered when making the decision to undergo orthodontic treatment. The major risks involved in orthodontic treatment may include:
  1. Tooth decay, gum disease and permanent markings (decalcification) on the teeth can occur if orthodontic patients eat foods or drink carbonated beverages containing excessive sugar and/or do not brush/floss their teeth frequently and properly. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces.
  2. In some patients the length of the roots of the teeth may be shortened during orthodontic treatment. Some patients are prone to this happening when the treatment plan involves the extraction of permanent teeth, but most are not.
  3. The health of the bone and gums which support the teeth may be affected by orthodontic tooth movement if a gum disease condition already exists and in some rare cases where a gum disease condition doesn’t appear to exist. In general, orthodontic treatment lessens the possibility of tooth loss or gum infection due to misalignment of the teeth or jaws. Inflammation of the gums and loss of supporting bone can occur if bacterial plaque is not removed daily with good oral hygiene.
  4. Teeth may have a tendency to change their positions after treatment. This is usually only a minor change and faithful wearing of retainers should reduce this tendency. Throughout life the bite can change adversely from various causes, such as eruption of wisdom teeth, growth and/or maturational changes, mouth breathing, tongue thrusting, severe chronic allergies, playing of musical instruments and other oral habits such as thumb sucking, all of which are out of the control of the orthodontist. Lifetime wear of bonded wire retainers is highly recommended to insure stability of both dental arches and to protect your considerable investment of time and funds.
  5. Occasionally problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing joint pain, headaches or ear problems (with or without orthodontic treatment). Any of the above noted symptoms should be promptly reported to the orthodontist.
  6. Sometimes a tooth may have been traumatized by a previous accident or a tooth may have large fillings which have caused damage to the nerve of the tooth. Orthodontic tooth movement may in some cases aggravate this pre-existing condition and in rare instances may lead to the need for root canal treatment.
  7. Sometimes orthodontic appliances may be accidentally swallowed or aspirated, or may irritate or damage the oral tissue. The gums, cheeks and lips may be scratched or irritated by loose or broken appliances or by blows to the mouth. Orthodontic wax and/or sugarless bubblegum placed on the irritation source will usually provide comfort until the next appointment. Usual post-adjustment tenderness should be expected and the period of tenderness or sensitivity varies with each patient and the procedure performed. (Typical post-adjustment tenderness may last 24-48 hours). You should inform your orthodontist of any unusual symptoms or broken or loose appliances, as soon as feasible.
  8. Abnormal wear of tooth structures is also possible if the patient grinds the teeth excessively.
  9. Sometimes oral surgery, tooth removal or orthognathic (jaw) surgery is necessary in conjunction with orthodontic treatment, especially to correct crowding or severe jaw imbalances. Risks involved with treatment and anesthesia should be discussed with your general dentist or oral surgeon before making your decision to proceed with this type of surgical procedure.
  10. Atypical formation of teeth or insufficient or abnormal changes in the growth of the jaws may limit our ability to achieve the desired result. If growth becomes disproportionate during or after treatment or a tooth forms very late, the bite may change requiring additional treatment or in some cases, oral surgery. Growth disharmony and unusual tooth formations are biological processes beyond the orthodontist’s control. Growth changes that occur after active orthodontic treatment may alter the quality of treatment results.
  11. The total time required to complete treatment may exceed the estimate. Excessive or deficient bone growth, poor cooperation in wearing the appliance the required hours per day, poor oral hygiene, broken appliances and missed appointments can lengthen the treatment time and affect the quality of the end results. After 5 broken brackets, a fee per bracket will be assessed to repair the orthodontic appliances. If treatment time exceeds 3 months of original estimate, an additional treatment fee of (our usual monthly) per month will incur until treatment is complete.
  12. Due to the wide variation in the size and shape of teeth, achievement of the most ideal result (for example, complete closure of excessive space) may require restorative dental treatment. The most common types of treatment are cosmetic bonding, crown and bridge restorative dental care and/or periodontal therapy. You are encouraged to ask questions regarding dental and medical care adjunctive to orthodontic treatment.
  13. General medical problems can affect orthodontic treatment. You should keep your orthodontist informed of any changes in your medical health.
POSSIBLE ALTERNATIVES
For the vast majority of patients, orthodontic treatment is an elective procedure. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present oral condition and decide to live without orthodontic correction or improvement. The specific alternative to the orthodontic treatment of any particular patient depends on the nature of the individual’s teeth, supporting structures and appearance. Alternatives could include:
  1. Extraction versus treatment without extraction
  2. Orthognathic (jaw) surgery versus treatment without orthognathic surgery
  3. Possible compromised approaches
APPOINTMENT TIMES
In an effort to better serve our patients and utilize our staff efficiently during working hours, it is necessary that each school age patient alternate appointments with one during school hours (excused absence) and the next not during school hours. This enables us to effectively eliminate long waits for all. Any appointment that is missed without a 24 hour prior telephone call will incur a FAILED APPOINTMENT FEE. We believe that our patients' time is very important. Thank you for helping us to coordinate your appointments efficiently.
PAYMENT PLANS
Your first fee will be for diagnostic records (x-rays, photos, and/or impressions). Once paid, (non-refundable), the records appointment may then be scheduled.
On the day of the diagnostic records appointment and financial consultation, the initial payment for TREATMENT (whichever payment plan was chosen) will be due. After the initial treatment payment has been made, all future monthly payments will be due at the beginning (1st) of each month.
 NOTE: If treatment begins after the 20th of the month, then your monthly payment will be due the second succeeding month. (example: if your "begin treatment" appointment is on June 21st, then your next monthly payment would be due August 1st , not July 1st). Appointment intervals are usually every 6-12 weeks and do not correspond with the monthly payment due date). There is a five day grace period for timely payments; on the sixth day a late payment fee will be applied to your account and every month thereafter until the account is brought current or up to date.
Payments will be collected utilizing Automatic Withdrawal from Credit Card, Debit Card or Checking account. If monthly payment coupons and monthly mailed or online payments are chosen, there will be a one-time Account Administration Fee due at the consultation appointment with the initial fee payment. Please let us know which option would be best for you.
REFERRAL REWARD FEE
If you have referred a patient to us, outside of immediate family, and they are in full active treatment before you are finished with your treatment, then you will receive $50.00 as a "thank you"!!
ORTHODONTIC INSURANCE
We will file and collect payment from your insurance company as a courtesy to you. Orthodontic insurance is not paid all at once. It is paid over the length of treatment in either monthly or quarterly intervals. If your insurance is ever cancelled or terminated, then you will be responsible for any remaining fee that the insurance did not pay. If your insurance company changes while you are in treatment, please let us know so we can continue to file in a timely manner (to the new insurance company). IF there is more than one change to a NEW insurance plan during treatment, for the THIRD insurance plan, there will be an administrative account maintenance fee of $100.00 for the initiation for claims (as well as for each succeeding (fourth,etc.) insurance company change thereafter.
INFORMED CONSENT TO UNDERGO ORTHODONTIC TREATMENT
The Doctors' Treatment Coordinators discussed the orthodontic treatment with me. She has presented information to aid in the decision-making process, and I have been given the opportunity to ask questions about the proposed orthodontic treatment and information contained in this form. I consent to the Doctors providing orthodontic treatment.
INVISALIGN:
Risks and Inconveniences
Like other orthodontic treatments, the use of Invisalign product (s) may involve some of the risks outlined below:
  1. Failure to wear the appliances for the required number of hours per day, not using the products as directed by your doctor, missing appointments, and atypically shaped teeth can lengthen the treatment time and affect the ability to achieve the desired results;
  2. Dental tenderness may be experienced after switching to the next aligner in the series;
  3. Gum, cheeks and lips may be scratched or irritated;
  4. Teeth may shift position after treatment. Faithful wearing of the retainers at the end of treatment should reduce this tendency;
  5. Tooth decay; periodontal disease, inflammation of the gums or permanent markings (e.g. decalcification) may occur if patients consume foods or beverages containing sugar, do not brush and floss their teeth properly before wearing the Invisalign products, or do not use proper oral hygiene and preventative maintenance;
  6. The aligners may temporarily affect speech and may result in a lisp, although any speech impediment caused by the Invisalign products should disappear within one or two days;
  7. Aligners may cause a temporary increase in salivation or mouth dryness and certain medicines can heighten this effect;
  8. Attachments may be bonded to one or more teeth during the course of treatment;
  9. Teeth may require interproximal recontouring or slenderizing in order to create space to allow tooth movement to occur:
  10. General medical conditions and use of medications can affect orthodontic treatment;
  11. Health of the bone and gums which support the teeth may be impaired or aggravated;
  12. Oral surgery may be necessary to correct crowding or severe jaw imbalances that are present prior to wearing the Invisalign product. If oral surgery is required, the risks associated with anesthesia and proper healing must be taken into account prior to treatment;
  13. A tooth that has been previously traumatized, or significantly restored may be aggravated. In rare instances the useful life of the tooth may be reduced, the tooth may require additional dental treatment such as endodontic and/or additional restorative work and the tooth may be lost;
  14. Existing dental restorations (e.g. crowns) may become dislodged and require re-cementation or in some instances, replacement;
  15. Short clinical crowns can pose appliance retention issues and inhibit tooth movement;
  16. The length of the roots of the teeth may be shortened during orthodontic treatment and may become a threat to the useful life of the tooth;
  17. Product breakage has a higher probability in case with multiple missing teeth;
  18. Orthodontic appliances or parts thereof may be accidentally swallowed or aspirated;
  19. In rare instances, problems may also occur in the jaw joint, causing jaw joint pain, headaches or ear problems;
  20. Allergic reactions may occur; and
  21. Teeth that are not at least partially covered by the aligner may undergo supraeruption
Informed Consent
I have been given adequate time to read and have read the preceding information describing orthodontic treatment with Invisalign aligners. I understand the benefits, risks and inconveniences associated with treatment. I have been sufficiently informed and have had the opportunity to ask questions and discuss concerns about orthodontic treatment with Invisalign products with my doctor from whom I intend to receive treatment. I understand that I should only use the Invisalign products after consultation and prescription from an Invisalign certified doctor, and I hereby consent to orthodontic treatment with Invisalign products that have been prescribed by my doctor.   Due to the fact that orthodontics is not an exact science, I acknowledge that my doctor and Align Technology, Inc. ("Align") have not and cannot make any guarantees or assurances concerning the outcome of my treatment. I understand that Align is not a provider of medical, dental or health care services and does not and cannot practice medicine, dentistry or give medical advice. No assurances or guarantees of any kind have been made to me by my doctor or Align, its representatives, successors, assigns, and agents concerning any specific outcome of my treatment.   I authorize my doctor to release my medical records, including, but not limited to, radiographs (x-rays), reports, charts, medical history, photographs, finding, plaster models or impressions of teeth, prescriptions, diagnosis, medical testing, test results, billing, and other treatment records in my doctor's possession ("Medical Records") (i) to other licensed dentists or orthodontists and organizations employing licensed dentists or orthodontists to Align, its representatives, employees, successors, assigns, and agents for the purposes of investigation and reviewing my medical history as it pertains to orthodontic treatment with product (s) from Align and (ii) for educational and research purposes.   I understand that use of my Medical Records may result in disclosure of my "individually identifiable health information" as defined by the Health Insurance Portability and Accountability Act ("HIPPA"). I hereby consent to the disclosure (s) as set forth above. I will not, nor shall anyone on my behalf seek legal, equitable or monetary damages or remedies for such disclosure.  I grant Ky. Center for Orthodontics, PSC the absolute right and permission to use, broadcast, reuse, publish and/or republish my photograph or video for print and/or digital/internet advertising purposes, with or without giving me "credit" or the privilege to inspect or approve prior to publication or broadcasting any use of my name, voice or likeness. I have read the above authorization and release prior to its execution and am familiar with the contents therein.
KMAP RULES ACKNOWLEDGEMENT
Welcome to our Orthodontic "family" of patients! Over the decades, Clear Choice Orthodontics has become one of Kentucky's most trusted resources for outstanding Orthodontic care.   Our reputation is founded on  attention to detail, professional integrity and total commitment to our patients. To provide you with the best quality Orthodontic care, we must ask that you strictly adhere to the following state and office regulations and policies:
1) Maintain a healthy and POSITIVE attitude  Orthodontic treatment is a privilege—not a right. Patient motivation is necessary for successful treatment results.   Our office will not initiate treatment on uncaring individuals.
2) Do NOT MISS any scheduled appointments.  Canceled and missed appointments may result in significant delays in treatment. Failure to appear for appointments will not be allowed allowed by the state of Kentucky. The State requires six visits during the first six months, if you do not make these appointments, appliances will be removed unless responsible party wants to pay for treatment.
3) Be ON TIME for all appointments. Punctuality demonstrates a respect for other patients within the practice. We value your time and know you would do the same for others.
4) Demonstrate flexibility with scheduling. We have reserved special appointment times specifically for your treatment. Procedures must be completed during the morning and early afternoon (8:30-2:30)  hours. We will provide school excuses.
5) Practice good oral hygiene. Proper brushing and flossing techniques must be maintained throughout the entire course of treatment. Inadequate home care will lead to cavities and gum disease, which will result in  immediate removal of the braces.
6) Take care of your braces. . Frequent breakage and neglect of your braces may lead to significant delays in treatment and unpleasant side effects. Frequent breakage of orthodontic appliances will result in immediate removal of the braces.
7) Wear your rubber bands as instructed. Excellent compliance is necessary to achieve excellent results. In order to keep your treatment on schedule, you must follow our specific directions for elastic wear.
8) Keep the lines of communication open. If at any time you have additional concerns or questions, please ask. Patients deserve the right to be well-informed regarding the treatment progress.
9) Keep your MEDICAL HISTORY, ADDRESS AND PHONE NUMBER current and accurate  We must always  be able to reach you for schedule changes when necessary.
Strict adherence to these policies is an absolute requirement for successful treatment at our office. Violations at any time during treatment will result in the state of Kentucky (KMAP) ordering immediate termination and dismissal from the state orthodontic program.  Please understand that these regulations are not being implemented for our own convenience but so that all patients may continue to benefit from our professional expertise. We look forward to an outstanding treatment result THAT WILL LAST A LIFETIME!