Patient Form OLD

Please email any relevant photos to records@smileorthodontics.

Date*

Patient Information

Sex*
Dentist's Name*
How did you learn of our office?*
Patient Marital Status*
Guardian Marital Status
Have you or any other family members been treated by our office?
Have you ever seen another orthodontist?*

Dental Insurance Information

Do you have dental/orthodontic insurance?*
Relationship to patient

Medical History

Are you presently taking any medications?*
Are you allergic to any medications?*
Do you have any history of major illness?*
Have you had any operations?*
Have you ever been involved in a serious accident?*
Have you seen a physician in the last 12 months?*
Are you pregnant?*
Do you have an allergy to nickel or latex?*
Check any of the medical conditions below that you have had or currently have.
Do you have any medical conditions not listed we should be aware of?*
I certify the above information is correct.*
Please verify the above information is correct to the best of your knowledge.

Dental History

Have you ever lost or chipped any teeth?*
Have you had any injuries to your face, mouth, or teeth?*
Is any part of your mouth sensitive to temperature?*
Is any part of your mouth sensitive to pressure?*
Do your gums bleed when brushing?*
Do you have any type of tongue or thumb habit?*
Do you smoke or use tobacco?*
Do you bite your nails?*
Do you play a musical instrument?*
Are you a mouth breather?*
Has anyone in your family received orthodontic treatment?*
Do your teeth or jaws ever feel uncomfortable first thing in the morning?*
Do you experience jaw clicking or popping?*
Do you clench or grind your teeth during the day?*
Do you experience "tension" headaches?*
Are you sensitive or self conscious about your teeth?*
I certify the above information is correct.*
Please verify the above information is correct to the best of your knowledge.

Privacy Consent (HIPPA)

Please list individuals to which we may disclose financial and treatment information regarding the patient.

I affirm this information to be accurate, and I will inform Smile Orthodontics of any changes in the medications or health status at the beginning of each appointment. My dental insurance company (if applicable) has my permission to pay benefits directly to Smile Orthodontics for services they have performed, although ultimate responsibility for payment the account is mine. I have read the notice of privacy practices. I authorize the orthodontic staff to perform the necessary dental services (including x-rays) we may need. I understand that if I take an x-ray performed at Smile Orthodontics to another orthodontic office that I might be charged. I understand that all original documents will be stored electronically. I understand that pictures of my teeth may be used for educational purposes.

POTENTIAL RISKS, LIMITATIONS, AND RECORDS CONSENT FOR ORTHODONTIC TREATMENT

Orthodontic treatment can help you have a pleasing smile. You should know that treatment with braces has limits and possible risks. Your treatment with braces usually goes as planned but results cannot be guaranteed. The risks of braces are seldom severe enough to offset the advantages of treatment, but you should know about them before choosing braces.

Health Updates - Many medical problems can affect your progress with braces. Tell us about all medications, allergies, and changes to your health. Some patients are allergic to the materials in the braces and rubber bands. If an allergic reactions occurs, braces may need to be stopped. Usually, special braces and rubber bands can be used to avoid an allergic reaction.

Treatment Time - Your time in braces is only an estimate. The actual time in braces may be shorter or longer. Excessive or deficient bone growth, poor cooperation, broken appliances, and missed appointments are all important factors that can lengthen treatment and affect the quality of the results.

Abnormal Jaw Growth - Occasionally, unexpected or abnormal changes in growth of the jaws may limit our ability to achieve the desired result. If your teeth and jaws do not grow as expected, your bite will change. If you have braces when this happens, you might need to be in braces longer or have jaw surgery. If abnormal tooth or jaw growth happens after you get your braces off, you may need to have braces again. Abnormal growth is something we cannot predict or control.

Temporomandibular Joint Disorders (TMD or TMJ) - Problems can occur in the jaw joints making it hard to open your mouth, giving you joint pain, headaches, ear aches, or pain when chewing. If you have any of these problems, please tell us right away. Braces do not cause or cure TMD or TMJ.

Discomfort - Getting braces and having adjustments to straighten your teeth can make your teeth and mouth sensitive or sore. Everyone is different, but in general, the soreness usually lasts 24 to 72 hours.

Injury with Braces - Your braces may poke or scratch your mouth. Parts of your braces may become loose or break if you get hit in the mouth or face from sports or horseplay. Eating hard or sticky foods can also break your braces. If parts of your braces become loose or break they may be swallowed or inhaled (breathed into the lungs). Even though headgears have a safety system, they can be dangerous. They can hurt your eyes and face.

Routine Dental Visits - General dental care and check-ups are the responsibility of the patient and your regular family dentist. We recommend that you be seen at least every six months by your family dentist during active orthodontic therapy. If you change your family dentist, please notify our office as soon as possible. 

Cavities, Decalcification, Gingivitis, Periodontal Disease - You can get cavities (tooth decay), decalcification (permanent white or brown spots on your teeth), gingivitis (red, puffy gums), or periodontal disease (loss of bone that supports your teeth) if you do not brush and floss your teeth frequently and properly, or eat foods with a lot of sugar. These same problems also occur in patients not in braces, but the risk is greater while in braces. Furthermore, the bone and gum tissue that support the teeth may be affected by orthodontic tooth movement if an unhealthy condition already exists. Tobacco use can increase your chance of getting gum disease and slows down healing in your mouth.

Root Resorption - Having braces can sometimes cause the roots of your teeth to get shorter. A past injury of your teeth can increase your chances of having this happen. In general, shortened roots are not a severe problem, but can sometimes lead to early loss of the teeth that are affected. If you get root resorption, we may stop or slow down treatment.

Traumatized Teeth - A large filling or an injury to a tooth from a past accident can damage the nerve inside the tooth. Straightening injured teeth can sometimes irritate the nerve and you may need to have a root canal on that tooth.

Extractions and Orthognathic Surgery - You may need to have some teeth removed or jaw surgery as part of your treatment. This is usually needed to fix severe crowding or severe mismatch of the jaws.

Impacted / Unerupted Teeth - Teeth that are stuck in the jaw and have not come into the mouth can be problems. They can cause loss of teeth, gum problems, and shortening of roots. Usually these teeth can be brought into the mouth. Some teeth become ankylosed (fused to the bone) and will not move. These teeth may need to be removed. These problems mean you may be in braces longer.

Tooth Reshaping (IPR/Enameloplasty) - Braces alone may not provide an ideal result. The best result may require changing the shape and size of your teeth. This may include reshaping or flattening some of your teeth by selective removal of enamel or adding filling material to make your teeth a different size.

Wisdom Teeth - As wisdom teeth develop, your teeth may change alignment. We, along with your dentist, will monitor them in order to determine when and if the wisdom teeth need to be removed.

Retainers - Teeth have a tendency to change their positions after treatment. Faithful wearing of retainers reduces this tendency. We recommend wearing retainers a minimum of sleep time indefinitely. A common site for these changes to occur is in the lower front teeth where some changes in tooth positions should be expected. The relationship of the upper to lower teeth can change adversely due to such problems as chronic mouth breathing, tongue thrusting, and abnormal jaw growth.

I have read, understood, and have had all my questions answered about the risks and limits of braces. I understand that things can change while I am in braces and the risk of continuing braces may become greater than the benefits. The braces should be stopped if this happens. I know that my treatment generally goes as planned but my results are not guaranteed.

Upon any diagnosis, I authorize Smile Orthodontics to perform all recommended treatment including X-rays, photos, and scans throughout treatment. I understand that I may ask for a full explanation of any possible complications. Please let us know if you have any questions.

I give my permission to Smile Orthodontics to use my photographs in media for marketing and advertising.

Please email any relevant photos to records@smileorthodontics.

Location

105 Valley West Dr,
West Des Moines 50265

Office Hours

MON - WED7:30 am-4:30 pm

THU7:30 am-3:30 pm

FRI - SUNClosed

Location

530 39th St,
Des Moines 50312

Office Hours

MON - WED7:30 am-4:30 pm

THU7:30 am-3:30 pm

FRI - SUNClosed