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If the patient is a minor, please fill out the following:

Responsible Party Information:

MEDICAL HISTORY

Please check medical conditions that you have/or have had.

ALLERGIES

Emergency Contact:

DENTAL HISTORY

Has The Patient:

DENTAL INSURANCE

Primary Dental Insurance Information:

Secondary Dental Insurance Information (If Applicable):

BILLING YOUR INSURANCE

As a courtesy to you, we take the responsibility for billing your insurance and awaiting their portion of payment due on your orthodontic account. In the event your insurance carrier denies payment for services rendered, for any reason, you are responsible for your account in full. If your insurance requires special signatures, forms or referrals, it is your responsibility to obtain them. We do not accept responsibility for any incorrect information given to us by your insurance company.

Please be aware that your insurance company may send letters and even checks for dental treatment to you 

throughout your orthodontic treatment. You are responsible for forwarding these items to us if required to maintain 

payment and/ or care of your account

RISK OF ORTHODONTIC TREATMENT

As a general rule, informed and cooperative patients can achieve positive orthodontic results. Thus, the following information is routinely supplied to all who are considering orthodontic treatment. While recognizing the benefits of healthy and a pleasing smile, you should also be aware that orthodontic treatment has limitations and potential risks.  These are seldom serious enough to indicate that treatment should be avoided, but they should be considered in making the decision whether to undergo orthodontic treatment. Orthodontic treatment usually proceeds as planned; however, as in all areas of the healing arts, results cannot be guaranteed, nor can all consequences be anticipated.

RISKS:

1. Tooth decay, gum disease, or permanent white marking (decalcification) on the teeth can occur, particularly if the patient eats food containing excessive sugar and/ or does not brush their teeth frequently and properly. These same problems can occur without orthodontic treatment, but the risk is greater to an individual with braces or other orthodontic appliances.

2. In some patients, the roots of some teeth may be shortened during orthodontic treatment. Usually, this shortening is minimal and does not have significant consequences, but on rare occasions it may become a treat to the longevity, stability, and/ or mobility of the teeth involved.

3. A typical formation of teeth or abnormal changes in the growth of the jaw may limit our ability to achieve the desired result. At times, changes after treatment require additional treatment or, in some cases, surgery. Growth disharmony and unusual tooth formations are biological processes beyond the

orthodontist’s control. Growth changes occur after active orthodontic treatment may adversely alter the treatment results.

4. The total time required to complete treatment may exceed the estimate. Excessive or deficient bone growth, poor cooperation in wearing the appliances or elastics the required hours per day, poor oral hygiene, broken appliances, missed appointments and other factors can lengthen the treatment time and can adversely affect the quality of the result.

5. General medical problems, such as bone, blood, or endocrine disorders, can affect orthodontic treatment. You should keep your orthodontist informed of any changes in your health.

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Consent: I consent to the use or disclosure of my protected health information for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct the health care operations of Dr. Cheryl Sorbero, DDS. I understand that diagnosis or treatment of me by Dr. Cheryl Sorbero, DDS may be conditioned upon my consent as evidence in my signature on this document.

Acknowledgement of Notice of Privacy Practices: I understand that Dr. Cheryl Sorbero, DDS notice of privacy practices describes the types of uses and disclosures of my protected health information that may occur in my treatment, payment of bills or in the performance of the health care operations of Dr. Cheryl Sorbero, DDS, notice of Privacy Practices has been provided to me.

Cancellation Policy: If you are not able to make your appointment, please notify our office at least 24 hours prior to the appointment. We reserve the right to charge a fee for appointments cancelled with less than 24 hours’ notice.

AUTHORIZATION TO DISCUSS YOUR DENTAL AND PAYMENT HISTORY WITH: