INITIAL RECORDS PAPERWORK

Patient Name *

First Name Last Name
INFORMED CONSENT

for the Orthodontic Patient
ACKNOWLEDGMENT

I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in the INFORMED CONSENT document that was given to me. I also understand that there may be other problems that occur less frequently than those presented, and that actual results may differ from the anticipated results. I also acknowledge that I have discussed this form with Dr. Panchura and have been give the opportunity to ask any questions. I have been asked to make a choice about my treatment. I hereby consent to the treatment proposed and authorize Dr. Panchura to provide the treatment. I also authorize Dr. Panchura to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by Dr. Panchura, and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.
PATIENT OR PARENT/GUARDIAN INITIALS *
CONSENT TO UNDERGO ORTHODONTIC TREATMENT

I hereby consent to the making of diagnostic records, including x-rays, before, during and following orthodontic treatment, and to Dr. Panchura and, where appropriate, staff providing orthodontic treatment prescribed by Dr. Panchura for the above individual. I full understand all of the risks associated with the treatment.
PATIENT OR PARENT/GUARDIAN INITIALS *
CONSENT TO USE OF RECORDS
May the patient’s picture be displayed on the office website and/or Facebook account for the purpose of informing patients of the positive outcomes we have achieved? *
May the patient's records including photographs be used for professional consultations, research, education or publication in professional journals? *
PLEASE NOTE:

Financial Disclosure: I understand that the practice is not receiving compensation from anyone for use of the patient’s photo.

Refusal to sign: I understand that refusal to sign part or all of this Authorization will in no way affect the patient’s treatment.

Revocation: I understand that I may revoke this authorization at any time by sending a written notice to the practice. All photos will be removed at the time the revocation is received.
I certify that I am the: *
Signature *

Clear
Printed Name *

First Name Last Name
Orthodontic Patient Contract
Successful orthodontic treatment results from the partnership between the orthodontic staff, patient, and parent. Orthodontic treatment is unique in health care as the time in braces, the fee, and the result depend entirely on the patient’s complete 100% participation.

Our promise:

1.     Explain procedures and keep you informed of your stage in treatment.

2.     To see our patients as promptly as possible. Note: Situations and emergencies arise and require more time than scheduled. If we run behind schedule – be patient. We will extend the same level of care and attention to you.

3.     Progress at every appointment, efficient treatment and optimum results. Which depend on the following:

Your promise:

1.     Keep your appointments. Missed appointments extend time in braces and increase your costs.

2.     Keep your teeth, dental appliances (braces), and especially gum tissue clean. Poor brushing will result in cavities and gum infections.

3.     Avoid hard and sticky foods that break braces. There will be additional charges for repair of braces.

4.     Wear elastics (rubber bands) 24/7 unless otherwise directed. Rubber bands are not a part of your treatment…they ARE your treatment.

5.     Keep current with payments and volunteer hours.

We will stop treatment because of repeated missed appointments, poor hygiene, multiple broken braces, lack of cooperation, delinquent payments and illegitimate volunteer hours.

I promise to do the following to the best of my ability:

1.     Keep my appointments.

2.     Keep my teeth, braces, and gum tissue clean.

3.     Avoid eating hard and sticky foods that can break my braces.

4.     Wear my rubber bands as instructed.

5.     Ask questions if I don't understand.

6.     Keep current with payments and volunteer hours.
PATIENT Signature (NOT PARENT) *

Clear
Parent Signature (if the patient is under 18 years of age) *

Clear
Date *

Month Day Year
Date
Should be Empty:

INFORMED CONSENT

CONSENT TO USE OF RECORDS

Orthodontic Patient Contract