New Patient (under 18) Registration Form Date: ______ PATIENT Last Name:____________________________ First Name: __________________ Middle Initial____ Birth Date: _______ Age:____ Sex: __Male __Female Prefers to be called:__________________ Home Address: _______________________________________________ Apt#: __________ City,State,& Zip Code: ___________________________ Home Phone: ______________________ School _____________________Grade_______ For Appointment Reminders: Cell Phone #: Email Address:___________________________________ PARENT/GUARDIAN Custodial Parent(s) Name(s):__________________________________________________________

Dentist Name:______________________________ Office Phone #_________________________ Father’s Name:________________________________________ Cell # : _____________________ Mother’s Name:________________________________________ Cell #:______________________ Dental Insurance: **Please Give Your Insurance Card to Our Receptionist Name of Dental Insurance Co: ID#:_________________________ Policy Holder’s Name: ________________________DOB: SS#: ________________________ Referred by (check) : __Dentist __Insurance __Internet __Friend/Patient (Who:_______________) Allergic to (circle) : Latex Yes/No Nickel (metal) Yes/No Medical Conditions?_________________________________________________________ Signature: ____________________________________

INFORMED CONSENT

for the Orthodontic PatientRisks and Limitations of Orthodontic Treatment

Orthodontics and Dentofacial Orthopedics is the dental specialty that includes the diagnosis, prevention,interception and correction of malocclusion, as well as neuromuscular and skeletal abnormalities of thedeveloping or mature orofacial structures.

An orthodontist is a dental specialist who has completed at least two additional years of graduate trainingin orthodontics at an accredited program after graduation from dental school.

Successful orthodontic treatment is a partnership between theorthodontist and the patient. The doctor and staff are dedicatedto achieving the best possible result for each patient. As a generalrule, informed and cooperative patients can achieve positiveorthodontic results. While recognizing the benefits of a beautifulhealthy smile, you should also be aware that, as with all healingarts, orthodontic treatment has limitations and potential risks.These are seldom serious enough to indicate that you should not

have treatment; however, all patients should seriously considerthe option of no orthodontic treatment at all by accepting theirpresent oral condition. Alternatives to orthodontic treatment varywith the individual’s specific problem, and prosthetic solutionsor limited orthodontic treatment may be considerations. You areencouraged to discuss alternatives with the doctor prior tobeginning treatment.

Results of TreatmentOrthodontic treatment usually proceeds as planned,and we intend to do everything possible to achievethe best results for every patient. However, we cannotguarantee that you will be completely satisfied withyour results, nor can all complications or consequencesbe anticipated. The success of treatment depends on your cooperation in keeping appointments,maintaining good oral hygiene, avoiding loose orbroken appliances, and following the orthodontist’sinstructions carefully.

Length of TreatmentThe length of treatment depends on a number ofissues, including the severity of the problem, thepatient’s growth and the level of patient cooperation.The actual treatment time is usually close to the estimated treatment time, but treatment may belengthened if, for example, unanticipated growth occurs,if there are habits affecting the dentofacial structures,if periodontal or other dental problems occur, or ifpatient cooperation is not adequate. Therefore, changesin the original treatment plan may become necessary.If treatment time is extended beyond the originalestimate, additional fees may be assessed.

DiscomfortThe mouth is very sensitive so you can expect anadjustment period and some discomfort due to the introduction of orthodontic appliances. Non-prescription pain medication can be used duringthis adjustment period.

RelapseCompleted orthodontic treatment does not guaranteeperfectly straight teeth for the rest of your life.Retainers will be required to keep your teeth in theirnew positions as a result of your orthodontic treat-ment. You must wear your retainers as instructed orteeth may shift, in addition to other adverse effects.Regular retainer wear is often necessary for severalyears following orthodontic treatment. However,changes after that time can occur due to naturalcauses, including habits such as tongue thrusting,mouth breathing, and growth and maturation thatcontinue throughout life. Later in life, most people willsee their teeth shift. Minor irregularities, particularlyin the lower front teeth, may have to be accepted.Some changes may require additional orthodontictreatment or, in some cases, surgery. Some situationsmay require non-removable retainers or other dentalappliances made by your family dentist.

ExtractionsSome cases will require the removal of deciduous(baby) teeth or permanent teeth. There are additionalrisks associated with the removal of teeth which youshould discuss with your family dentist or oral surgeonprior to the procedure.

Orthognathic SurgerySome patients have significant skeletal disharmonieswhich require orthodontic treatment in conjunctionwith orthognathic (dentofacial) surgery. There areadditional risks associated with this surgery which youshould discuss with your oral and/or maxillofacial

surgeon prior to beginning orthodontic treatment.Please be aware that orthodontic treatment prior toorthognathic surgery often only aligns the teeth withinthe individual dental arches. Therefore, patients discon-tinuing orthodontic treatment without completing theplanned surgical procedures may have a malocclusionthat is worse than when they began treatment!

Decalcification and Dental CariesExcellent oral hygiene is essential during orthodontictreatment as are regular visits to your family dentist.Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/ordecalcification. These same problems can occurwithout orthodontic treatment, but the risk is greaterto an individual wearing braces or other appliances.These problems may be aggravated if the patient has not had the benefit of fluoridated water or itssubstitute, or if the patient consumes sweetened bev-erages or foods.

Root ResorptionThe roots of some patients’ teeth become shorter(resorption) during orthodontic treatment. It is notknown exactly what causes root resorption, nor is itpossible to predict which patients will experience it.However, many patients have retained teeth through-out life with severely shortened roots. If resorption isdetected during orthodontic treatment, your ortho-dontist may recommend a pause in treatment or theremoval of the appliances prior to the completion oforthodontic treatment.

Nerve DamageA tooth that has been traumatized by an accident ordeep decay may have experienced damage to the nerveof the tooth. Orthodontic tooth movement may, insome cases, aggravate this condition. In some cases,root canal treatment may be necessary. In severe cases,the tooth or teeth may be lost.

Periodontal DiseasePeriodontal (gum and bone) disease can develop orworsen during orthodontic treatment due to manyfactors, but most often due to the lack of adequateoral hygiene. You must have your general dentist, orif indicated, a periodontist monitor your periodontalhealth during orthodontic treatment every three to sixmonths. If periodontal problems cannot be controlled,orthodontic treatment may have to be discontinuedprior to completion.

Injury From Orthodontic AppliancesActivities or foods which could damage, loosen ordislodge orthodontic appliances need to be avoided.Loosened or damaged orthodontic appliances can beinhaled or swallowed or could cause other damageto the patient. You should inform your orthodontistof any unusual symptoms or of any loose or brokenappliances as soon as they are noticed. Damage to theenamel of a tooth or to a restoration (crown, bonding,veneer, etc.) is possible when orthodontic appliancesare removed. This problem may be more likely whenesthetic (clear or tooth colored) appliances have beenselected. If damage to a tooth or restoration occurs,restoration of the involved tooth/teeth by your dentistmay be necessary.

HeadgearsOrthodontic headgears can cause injury to the patient.Injuries can include damage to the face or eyes. In theevent of injury or especially an eye injury, howeverminor, immediate medical help should be sought.Refrain from wearing headgear in situations wherethere may be a chance that it could be dislodged orpulled off. Sports activities and games should beavoided when wearing orthodontic headgear.

Temporomandibular (Jaw) Joint DysfunctionProblems may occur in the jaw joints, i.e., temporo-mandibular joints (TMJ), causing pain, headaches orear problems. Many factors can affect the health ofthe jaw joints, including past trauma (blows to thehead or face), arthritis, hereditary tendency to jawjoint problems, excessive tooth grinding or clenching,poorly balanced bite, and many medical conditions.Jaw joint problems may occur with or without ortho-dontic treatment. Any jaw joint symptoms, includingpain, jaw popping or difficulty opening or closing,should be promptly reported to the orthodontist.Treatment by other medical or dental specialists maybe necessary.

Impacted, Ankylosed, Unerupted TeethTeeth may become impacted (trapped below the boneor gums), ankylosed (fused to the bone) or just fail toerupt. Oftentimes, these conditions occur for no apparentreason and generally cannot be anticipated. Treatmentof these conditions depends on the particular circum-stance and the overall importance of the involvedtooth, and may require extraction, surgical exposure,surgical transplantation or prosthetic replacement.

Occlusal AdjustmentYou can expect minimal imperfections in the way yourteeth meet following the end of treatment. An occlusalequilibration procedure may be necessary, which is a grinding method used to fine-tune the occlusion.It may also be necessary to remove a small amountof enamel in between the teeth, thereby “flattening”surfaces in order to reduce the possibility of a relapse.

Non-Ideal ResultsDue to the wide variation in the size and shape of theteeth, missing teeth, etc., achievement of an ideal result(for example, complete closure of a space) may not bepossible. Restorative dental treatment, such as estheticbonding, crowns or bridges or periodontal therapy,may be indicated. You are encouraged to ask yourorthodontist and family dentist about adjunctive care.

Third MolarsAs third molars (wisdom teeth) develop, your teeth maychange alignment. Your dentist and/or orthodontistshould monitor them in order to determine when andif the third molars need to be removed.

Patient or Parent/Guardian Initials ___________

Continued on next page

ACKNOWLEDGEMENT

I hereby acknowledge that I have read and fullyunderstand the treatment considerations andrisks presented in this form. I also understandthat there may be other problems that occurless frequently than those presented, and thatactual results may differ from the anticipatedresults. I also acknowledge that I have discussedthis form with the undersigned orthodontist(s)and have been given the opportunity to ask anyquestions. I have been asked to make a choiceabout my treatment. I hereby consent to thetreatment proposed and authorize the orthodon-tist(s) indicated below to provide the treatment.I also authorize the orthodontist(s) to providemy health care information to my other healthcare providers. I understand that my treatmentfee covers only treatment provided by theorthodontist(s), and that treatment provided by other dental or medical professionals is notincluded in the fee for my orthodontic treatment.

Signature of Patient/Parent/Guardian Date

Signature of Orthodontist/Group Name Date

Witness Date

CONSENT TO UNDERGO ORTHODONTIC TREATMENT

I hereby consent to the making of diagnosticrecords, including x-rays, before, during andfollowing orthodontic treatment, and to theabove doctor(s) and, where appropriate, staffproviding orthodontic treatment prescribed by the above doctor(s) for the above individual.I fully understand all of the risks associated withthe treatment.

AUTHORIZATION FOR RELEASE OFPATIENT INFORMATION

I hereby authorize the above doctor(s) to provideother health care providers with informationregarding the above individual’s orthodontic careas deemed appropriate. I understand that oncereleased, the above doctor(s) and staff has(have)no responsibility for any further release by theindividual receiving this information.

CONSENT TO USE OF RECORDS

I hereby give my permission for the use oforthodontic records, including photographs,made in the process of examinations, treat-ment, and retention for purposes of profession-al consultations, research, education, or publi-cation in professional journals.

Signature Date

Witness Date

I have the legal authority to sign this on behalf of

Name of Patient

Relationship to Patient

Patient or Parent/Guardian Initials ___________

Patient _________________________________ Date _______________

AllergiesOccasionally, patients can be allergic to some of thecomponent materials of their orthodontic appliances.This may require a change in treatment plan or discontinuance of treatment prior to completion.Although very uncommon, medical management ofdental material allergies may be necessary.

General Health ProblemsGeneral health problems such as bone, blood orendocrine disorders, and many prescription and non-prescription drugs (including bisphosphonates)can affect your orthodontic treatment. It is imperativethat you inform your orthodontist of any changes inyour general health status.

Use of Tobacco ProductsSmoking or chewing tobacco has been shown toincrease the risk of gum disease and interferes withhealing after oral surgery. Tobacco users are also moreprone to oral cancer, gum recession, and delayedtooth movement during orthodontic treatment. Ifyou use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

Temporary Anchorage DevicesYour treatment may include the use of a temporaryanchorage device(s) (i.e. metal screw or plate attachedto the bone.) There are specific risks associated withthem.

It is possible that the screw(s) could become loosewhich would require its/their removal and possiblyrelocation or replacement with a larger screw. Thescrew and related material may be accidentally swal-lowed. If the device cannot be stabilized for an ade-quate length of time, an alternate treatment plan maybe necessary.

It is possible that the tissue around the device couldbecome inflamed or infected, or the soft tissue couldgrow over the device, which could also require itsremoval, surgical excision of the tissue and/or the useof antibiotics or antimicrobial rinses.

It is possible that the screws could break (i.e. uponinsertion or removal.) If this occurs, the broken piecemay be left in your mouth or may be surgicallyremoved. This may require referral to another dentalspecialist.

When inserting the device(s), it is possible to damagethe root of a tooth, a nerve, or to perforate the maxil-lary sinus. Usually these problems are not significant;however, additional dental or medical treatment maybe necessary.

Local anesthetic may be used when these devices areinserted or removed, which also has risks. Please advisethe doctor placing the device if you have had anydifficulties with dental anesthetics in the past.

If any of the complications mentioned above dooccur, a referral may be necessary to your family dentist or another dental or medical specialist forfurther treatment. Fees for these services are notincluded in the cost for orthodontic treatment.

Notes

401 N. Lindbergh Blvd.St. Louis, MO, USA 63141-7816

800.424.2841 Toll Free314.997.6968 outside of the US and Canada

314.993.6992 Faxorders@aaortho.org

www.AAOmembers.org

© 2005 American Association of Orthodontists

Financial Policy Options In effort to help you in budgeting the financial portion of your orthodontic investment, we have several payment options:

• Option 1 – Interest Free, Low down payment and up to 24 months to pay for treatment

• Option 2 – CareCredit or Lending Point with zero down and

extended payment plans with low monthly payments (beyond 24 months will include a finance charge). Insurance is applied to your financial portion.

With CareCredit or Lending Point:

1. Monthly payments to fit almost every budget. 2. There are no annual fees or prepayment penalties. 3. It’s a separate line of credit to cover you and your family’s healthcare needs, leaving existing credit available for emergencies and other purchases. 4. Take advantage for your down payment or the total treatment fee.

*Insurance is applied to total treatment cost and the remaining patient balance is paid according to option selected above.

NOTE: Please remember that you are ultimately responsible for all charges incurred and that you are responsible for any balance not paid by your insurance company. We accept Cash, Money Orders, Personal Checks, American Express, Visa, MasterCard and Discover and offer third party financing through CareCredit and Lending Point.

Go to www.carecredit.com (Lending Point is for Invisalign treatment Financing)

Practice limited to Orthodontics Jeffrey J. Kim, D.D.S. (914) 946-9098

90 Bryant Avenue

1C Embassy Building

White Plains, N.Y. 10605

PATIENT HIPAA AWARENESS

With my permission, Dr. Jeffrey J. Kim, may use, and disclose Protected Health Information (PHI) about

me to carry out treatment, payment and healthcare operations (TPO). Please refer to Dr. Kim’s Notice of

Privacy Practices for a more complete description of such issues and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Dr. Kim reserves

the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may

be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Dr. Kim may call my home or other designated locations and leave a

message on voicemail or in person in reference to any items that assist the practice in carrying out TPO,

such as appointment reminders, insurance items and any call pertaining to my clinical care, including

laboratory results among others.

With my permission the office of Dr. Kim may mail to my home or other designated locations any items

that assist the practice in carrying out TPO, such as appointment card reminders and patient statements as

long as they are marked personal and/or confidential.

I have the right to request that Dr. Kim restrict how it uses or discloses my PHI to carry out TPO.

However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by

this agreement.

By signing this, I am allowing Dr. Kim to use and disclose my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in

reliance upon my prior consent.

______________________________

Signature of Patient or Legal Guardian

______________________________ ___________________

Patient’s Name Date

Print Name of Patient or Legal Guardian_________________________________________________

White Plains Orthodontics, PC

Supplemental Consent/Acknowledgement Form

By signing below and circling “yes”, you consent to allow White Plains

Orthodontics, PC to do the following.

o Display your first name and photograph in our office. Yes No

o Display your first name and photograph on our website. Yes No

o Use your orthodontic records for educational purposes. Yes No

Patient’s Name _____________________________________Date________

Signature_________________________________________