Regarding Patient:


I hereby authorize that all necessary orthodontic treatment be initiated now. This shall include the making of appropriate diagnostic records whenever needed. I understand the treatment goals can only be achieved through the joint cooperation of Dr. Rothstein, and the patient (and responsible custodial parent (s)). In many instances lack of cooperation in the matter of making and keeping appointments, eating a soft diet, wearing elastics, brushing the teeth 3 times each day for 3 minutes each time and finally, insufficient wearing of retainers can be the cause of failure to reach the treatment goals. I understand also that I am responsible for making monthly appointments.

I understand that treatment varies with the difficulty of the problem, cooperation of the patient, and the unique response of the patientís teeth to the forces applied to them. Treatment time can be prolonged by multiple detached brackets (from eating crispy crunchy and crusty food and candy), poor oral hygiene, frequent canceling of appointments and broken appointments. Occasionally, as a result of unusual growth or lack of cooperation or mid-treatment re-evaluation the treatment plan/goals may have to be altered and might even require the removal of teeth to accomplish a pleasing cosmetic and functional result.

I understand that during treatment the following may occur: cold sores, canker sores, irritation or injury to the skim inside the mouth, selling/inflammation of the gums, receding of the gums, overgrowth of the gums, and shortening of the roots of some teeth.

I understand that teeth may develop white spots if tooth brushing is inadequate, that cavities previously undetected may appear and that teeth with a history of trauma may turn grayish in color.

I understand that teeth may occasionally become sensitive and more movable than usual and that there us a risk of unexpected/undesired loss of a tooth.

I understand that occasionally the joints may "act up" causing discomfort/pain, that there may be an allergic reaction to the materials of which the braces are made or even the gloves and powder on them that the doctor wears. I realize that some cases might require the need for a "compromise" treatment goal and that a general dentist may be required to provide crowns and bridges and bonding to fill in spaces between teeth that could not be closed by orthodontic treatment.

I realize that during the treatment it is possible that a doctor who does do root canal treatment and gum surgery may need to be consulted. Finally, that it is possible that dental materials and parts of the braces may inadvertently be swallowed or taken into the airway.

I understand the need for a soft-textured diet to prevent brackets from becoming detached. I have been advised that it is important to continue regular dental care during the treatment. I have been advised that it is my responsibility to immediately report any problems with the braces. I realize that Dr. Rothstein may discontinue treatment if he believes that the patientís oral health is degenerating from lack of cooperation or improper home care.

Dr. Rothstein will use his knowledge, skill and training to do his very best, but there is no guarantee of the success of treatment and that a nice result may deteriorate if retainers are not worn for three years after the braces are removed. The alternatives have been explained to me, one of which is no treatment and the possible results if no treatment is given. The treatment plan and type of appliances to be used have been explained to me. Furthermore, I am at liberty to ask Dr. Rothstein at any time during the treatment about any aspect of my treatment.

I understand there is no specific warranty or guarantee as to any result/cure, and I understand that I can ask for, at any time, a full recital if all possible risks related to all phases of my treatment.

I understand the variables associated with the degree of success to be achieved and have read and fully understand the above information and that I may ask for further explanation of this document.

I have been cautioned that sometimes Dr. Rothstein needs to change the clear-transparent braces to metal braces, and the lingual braces to regular front braces (clear) in the last 3 months of treatment to achieve a proper level of perfection in the final result, and I agree to let him make that change if he thinks it is needed.


Patient/Responsible Party                                                                   Date    /   /2001