INFORMED CONSENT FOR THE PEDIATRIC PATIENT

Risks and Limitations of Pediatric Dental Treatment

State law requires health professionals to provide their prospective patients with information regarding the treatment or procedures they are contemplating. State Law also requires us to obtain your consent for any specific dental treatment, procedures or techniques, which might be considered to be of concern to the patient or parent. Informed consent indicates your awareness of sufficient information to allow you to make an informed personal choice concerning your child’s dental treatment after considering the risks, benefits, and alternatives.

Please read this form carefully and ask about anything you do not understand. We will be pleased to explain it.

It is our intent that all professional care delivered in our dental operatories shall be of the best possible quality we can provide for each child. Providing a high quality care can sometimes be made very difficult or even impossible, because of the lack of cooperation of some child patients. Among the behaviors that can interfere with the proper provision of quality dental care are: hyperactivity, resistive movements, refusing to open the mouth or keep it open long enough to perform the necessary dental treatment, and even aggressive or physical resistance to treatment, such as kicking, screaming, and grabbing the dentist’s hands or the sharp dental instruments.

There are several behavior management techniques that are used by pediatric dentists to gain the cooperation of child patients to eliminate disruptive behavior or prevent patients from causing injury to themselves due to uncontrollable movement. The more frequently used pediatric dentistry behavior management techniques are as follows:

1. Tell-show-do: The dentist or assistant explains to the child what is to be done using simple terminology and repetition and then shows the child what is to be done by demonstrating with instruments on a model or the child’s or dentist’s finger. Then the procedure is performed in the child’s mouth as described. Praise is used to reinforce cooperative behavior.

2. Positive reinforcement: This technique rewards the child who displays any behavior, which is desirable. Rewards include compliments, praise, a pat on the back, a hug or a prize.

3. Voice Control: The attention of a disruptive child is gained by changing the tone or increasing the volume of the dentist’s voice. Content of the conversation is less important than the abrupt or sudden nature of the command.

4. Mouth props: A rubber or plastic device is placed in the child’s mouth to prevent closing when a child refuses or has difficulty maintaining an open mouth.

5. Physical restraint by the dentist: The dentist restrains the child from movement by holding down the child’s hands or upper body, stabilizing the child’s head between the dentist’s arm and body, or positioning the child firmly in the dental chair.

6. Physical restraint by the assistant: The assistant restrains the child from movement by holding the child’s hands, stabilizing the head, and/or controlling leg movements.

7. Papoose Boards and Pedi-Wraps: These are restraining devices for limiting the disruptive child’s movements to prevent injury and to enable the dentist to provide the necessary treatment. The child is wrapped in these devices and placed in a reclined dental chair.

8. General anesthesia: The dentist performs the dental treatment with the child anesthetized in the hospital operating room. Your child will not be given general anesthesia without you being further informed and obtaining your specific consent for such procedure.

9. Parent Involvement: We welcome parents to attend while the patient’s teeth are examined and cleaned. The parent(s) should use this opportunity to familiarize and comfort the child with the dentist experience in preparation of future visits. No one (including parents) is allowed to attend while the patient receives treatment by the doctor(s). Often parents hinder treatment rather than help. If this poses a problem in accepting treatment in our office, we will happily refer you to another pediatric dentist.

This listed pediatric dentistry behavior management techniques have been explained to me. I have had explained to me by Dr. Burleson or associates, and have had sufficient opportunity to discuss the patient's dental condition / problem(s), the planned procedures and treatment, and the benefits to be reasonably expected from this treatment plan, compared with alternative approaches and/or no treatment.

Although their occurrence is extremely remote, some risks are known to be associated with dental procedures. The usual and most frequent risks or complications occurring from the planned treatment and procedures also have been explained to me. These risks or complications occurring from the planned treatment include, swelling, infection, bleeding, injury to adjacent teeth and surrounding tissue, development of a temporomandibular joint disorder, temporary or permanent numbness, and allergic reactions. Occasionally, a child may also chew / irritate his or her own cheek, lip or tongue while numb. It is the responsibility of the parent to closely monitor children who are numb in order to decrease the risk of such complication.

I hereby authorize and direct Burleson Orthodontics & Pediatric Dentistry, to utilize the behavior management techniques listed above to assist in the provision of the necessary dental treatment for my child (or legal ward).

I hereby acknowledge that I have read and understand this consent, and that all questions about the behavior management techniques described have been answered in a satisfactory manner, and I further understand that I have the right to be provided with answers to questions which may arise during the course of my child’s treatment.

I further understand that this consent shall remain in effect until terminated by me.

CONSENT TO UNDERGO TREATMENT:

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis.

Upon such diagnosis, I authorize doctor, associates and clinical technicians to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I am aware of and hereby agree to treatment in a clinical setting that allows patients-only in the treatment area (operatories) in order to provide care in a safe environment free from distractions.

I agree that the terms and details of my care are to be kept confidential and will not be disclosed to anyone (specifically including but not limited to online reviews and social media) without written authorization of the doctor or an order from a court of competent jurisdiction. 

I agree to the use of anesthetics, sedatives, fluoride and other medication as necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I can ask for a complete recital on any possible complication.

I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% late charge (18% APR) may be added to my account. 

I hereby give Dr. Burleson the absolute right and permission to use my photographs and dental records for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs and dental records.

 

INFORMED CONSENT FOR THE ORTHODONTIC PATIENT
Risks and Limitations of Orthodontic Treatment

Successful orthodontic treatment is a partnership between the orthodontist and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, 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 consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning 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 the developing or mature orofacial structures.

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

Results of Treatment - Orthodontic treatment usually proceeds as planned, and we intend to do everything possible to achieve the best results for every patient. However, we cannot guarantee that you will be completely satisfied with your results, nor can all complications or consequences be anticipated. The success of treatment depends on your cooperation in keeping appointments, maintaining good oral hygiene, avoiding loose or broken appliances, and following the orthodontist’s instructions carefully.

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

Discomfort - The mouth is very sensitive so you can expect an adjustment period and some discomfort due to the introduction of orthodontic appliances. Non- prescription pain medication can be used during this adjustment period.

Relapse - Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Retainers will be required to keep your teeth in their new positions as a result of your orthodontic treat- ment. You must wear your retainers as instructed or teeth may shift, in addition to other adverse effects. Regular retainer wear is often necessary for several years following orthodontic treatment. However, changes after that time can occur due to natural causes, including habits such as tongue thrusting, mouth breathing, and growth and maturation that continue throughout life. Later in life, most people will see their teeth shift. Minor irregularities, particularly in the lower front teeth, may have to be accepted. Some changes may require additional orthodontic treatment or, in some cases, surgery. Some situations may require non-removable retainers or other dental appliances made by your family dentist.

Extractions - Some cases will require the removal of deciduous (baby) teeth or permanent teeth. There are additional risks associated with the removal of teeth which you should discuss with your family dentist or oral surgeon prior to the procedure.

Orthognathic Surgery - Some patients have significant skeletal disharmonies which require orthodontic treatment in conjunction with orthognathic (dentofacial) surgery. There are additional risks associated with this surgery which you should discuss with your oral and/or maxillofacial surgeon prior to beginning orthodontic treatment. Please be aware that orthodontic treatment prior to orthognathic surgery often only aligns the teeth within the individual dental arches. Therefore, patients discontinuing orthodontic treatment without completing the planned surgical procedures may have a malocclusion that is worse than when they began treatment.

Decalcification and Dental Caries - Excellent oral hygiene is essential during orthodontic treatment as are regular visits to your family dentist. Inadequate or improper hygiene could result in cavities, discolored teeth, periodontal disease and/or decalcification. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces or other appliances. These problems may be aggravated if the patient has not had the benefit of fluoridated water or its substitute, or if the patient consumes sweetened bev- erages or foods.

Root Resorption - The roots of some patients’ teeth become shorter (resorption) during orthodontic treatment. It is not known exactly what causes root resorption, nor is it possible to predict which patients will experience it. However, many patients have retained teeth through- out life with severely shortened roots. If resorption is detected during orthodontic treatment, your ortho- dontist may recommend a pause in treatment or the removal of the appliances prior to the completion of orthodontic treatment.

Nerve Damage - A tooth that has been traumatized by an accident or deep decay may have experienced damage to the nerve of the tooth. Orthodontic tooth movement may, in some cases, aggravate this condition. In some cases, root canal treatment may be necessary. In severe cases, the tooth or teeth may be lost.

Periodontal Disease - Periodontal (gum and bone) disease can develop or worsen during orthodontic treatment due to many factors, but most often due to the lack of adequate oral hygiene. You must have your general dentist, or if indicated, a periodontist monitor your periodontal health during orthodontic treatment every three to six months. If periodontal problems cannot be controlled, orthodontic treatment may have to be discontinued prior to completion.

Injury From Orthodontic Appliances - Activities or foods which could damage, loosen or dislodge orthodontic appliances need to be avoided. Loosened or damaged orthodontic appliances can be inhaled or swallowed or could cause other damage to the patient. You should inform your orthodontist of any unusual symptoms or of any loose or broken appliances as soon as they are noticed. Damage to the enamel of a tooth or to a restoration (crown, bonding, veneer, etc.) is possible when orthodontic appliances are removed. This problem may be more likely when esthetic (clear or tooth colored) appliances have been selected. If damage to a tooth or restoration occurs, restoration of the involved tooth/teeth by your dentist may be necessary.

Headgears - Orthodontic headgears can cause injury to the patient. Injuries can include damage to the face or eyes. In the event of injury or especially an eye injury, however minor, immediate medical help should be sought. Refrain from wearing headgear in situations where there may be a chance that it could be dislodged or pulled off. Sports activities and games should be avoided when wearing orthodontic headgear.

Temporomandibular (Jaw) - Joint Dysfunction - Problems may occur in the jaw joints, i.e., temporo- mandibular joints (TMJ), causing pain, headaches or ear problems. Many factors can affect the health of the jaw joints, including past trauma (blows to the head or face), arthritis, hereditary tendency to jaw joint 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, including pain, jaw popping or difficulty opening or closing, should be promptly reported to the orthodontist. Treatment by other medical or dental specialists may be necessary.

Impacted, Ankylosed, Unerupted Teeth - Teeth may become impacted (trapped below the bone or gums), ankylosed (fused to the bone) or just fail to erupt. Oftentimes, these conditions occur for no apparent reason and generally cannot be anticipated. Treatment of these conditions depends on the particular circum- stance and the overall importance of the involved tooth, and may require extraction, surgical exposure, surgical transplantation or prosthetic replacement.

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

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

Third Molars - As third molars (wisdom teeth) develop, your teeth may change alignment. Your dentist and/or orthodontist should monitor them in order to determine when and if the third molars need to be removed.

Allergies - Occasionally, patients can be allergic to some of the component 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 of dental material allergies may be necessary.

General Health Problems - General health problems such as bone, blood or endocrine disorders, and many prescription and non- prescription drugs (including bisphosphonates) can affect your orthodontic treatment. It is imperative that you inform your orthodontist of any changes in your general health status.

Use of Tobacco Products - Smoking or chewing tobacco has been shown to increase the risk of gum disease and interferes with healing after oral surgery. Tobacco users are also more prone to oral cancer, gum recession, and delayed tooth movement during orthodontic treatment. If you use tobacco, you must carefully consider the possibility of a compromised orthodontic result.

Temporary Anchorage Devices - Your treatment may include the use of a temporary anchorage device(s) (i.e. metal screw or plate attached to the bone.) There are specific risks associated with them.

It is possible that the screw(s) could become loose which would require its/their removal and possibly relocation or replacement with a larger screw. The screw 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 may be necessary.

It is possible that the tissue around the device could become inflamed or infected, or the soft tissue could grow over the device, which could also require its removal, surgical excision of the tissue and/ or the use of antibiotics or antimicrobial rinses.

It is possible that the screws could break (i.e. upon insertion or removal.) If this occurs, the broken piece may be left in your mouth or may be surgically removed. This may require referral to another dental specialist.

When inserting the device(s), it is possible to damage the 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 may be necessary.

Local anesthetic may be used when these devices are inserted or removed, which also has risks. Please advise the doctor placing the device if you have had any difficulties with dental anesthetics in the past.

If any of the complications mentioned above do occur, a referral may be necessary to your family dentist or another dental or medical specialist for further treatment. Fees for these services are not included in the cost for orthodontic treatment.

ACKNOWLEDGEMENT:

I hereby acknowledge that I have read and fully understand the treatment considerations and risks presented in this form. 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 the undersigned orthodontist(s) and have been given 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 the orthodon- tist(s) indicated below to provide the treatment. I also authorize the orthodontist(s) to provide my health care information to my other health care providers. I understand that my treatment fee covers only treatment provided by the orthodontist(s), and that treatment provided by other dental or medical professionals is not included in the fee for my orthodontic treatment.

I hereby give my permission for the use of orthodontic records, including photographs, made in the process of examinations, treatment, and retention for purposes of professional consultations, research, education, or publication in professional journals.

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 the above doctor(s) and, where appropriate, staff providing orthodontic treatment prescribed by the above doctor(s) for the above individual. I fully understand all of the risks associated with the treatment.

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis.

Upon such diagnosis, I authorize doctor, associates and clinical technicians to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I am aware of and hereby agree to treatment in a clinical setting that allows patients-only in the treatment area (operatories) in order to provide care in a safe environment free from distractions.

I agree that the terms and details of my care are to be kept confidential and will not be disclosed to anyone (specifically including but not limited to online reviews and social media) without written authorization of the doctor or an order from a court of competent jurisdiction.

I agree to the use of anesthetics, sedatives, fluoride and other medication as necessary. I fully understand that using anesthetic agents embodies a certain risk. I understand that I can ask for a complete recital on any possible complication.

I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% late charge (18% APR) may be added to my account.

I hereby give Dr. Burleson the absolute right and permission to use my photographs / slides for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides.

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information, please review it carefully.

Confidentiality Practices:

Burleson Orthodontics & Pediatric Dentistry is committed to protecting your health information. This notice explains how we will use, share and protect your health information. It also explains your rights to privacy of your health information as required by law. If our confidentiality practices change, a new notice will be mailed to you within sixty (60) days of the change.

Uses, Sharing and Protection of Health Information:

The law only allows our staff to use your health information when doing their jobs or to share your information when it is necessary to run the program. When health information is shared with other agencies or organizations, our office requires them to keep your health information confidential. Your health information will be shared to approve or deny treatment, and to determine if you are getting the right dental treatment. For example, doctors and assistants employed by our practice may review the treatment plan created for you by your health care provider to make sure the care you receive is covered by your dental insurance.

The Practice Will Use and Share Your Health Information Without Authorization to:

• Make payments to your health care providers for dental services provided to you.
• Coordinate payment for your care between the practice, other health plans, and other insurance companies that may be responsible for the cost of your care.
• Coordinate your care between the practice, other health plans, and health care providers to improve the quality of your health care.
• Evaluate the performance of your health care provider. For example, the practice contracts with consultants to review office and other facilities’ medical records to check on the quality of care you received.
• Release information to its attorneys, accountants, and consultants so that the practice is run efficiently and to detect and prosecute insurance fraud and abuse.
• Send you helpful information such as insurance benefit updates, free orthodontic exams and consumer protection information.
• Share information with government agencies or organizations that provide benefits or services when the information is necessary in order for you to receive those benefits or services.

The Practice May Disclose Your Health Information Without Authorization:

• To public health agencies for activities such as disease control and prevention, problems with medical products or medications.
• If you are the victim of abuse, neglect or domestic violence.
• To health oversight agencies responsible for the Medicaid Program such as the U.S. Department of Health and Human Services and its Office of Civil Rights.
• In court cases or judicial and administrative hearings when required by law to run the practice.
• To coroners, medical examiners, and funeral directors so they can carry out their jobs as required by law.
• To organizations involved with organ donation and transplantation, communicable disease registries and cancer registries.
• To entities authorized to conduct a research project.
• To prevent a serious threat to a person’s or the public’s health and safety.
• To the military if you are or have been a member of the armed services.
• To a correctional facility or law enforcement officials to maintain the health, safety, and security of the corrections systems, if you are held in custody.
• To workers’ compensation programs that provide benefits for work-related injuries or illness without regard to fault.
• To law enforcement or national security and intelligence agencies, and to protect the President and others as required by law.

Uses and Disclosures of Protected Information Based on Your Written Authorization

All other uses and disclosures will be made only with your written authorization. These may include:

• Most uses and disclosures of your treatment notes will require your authorization
• Any use or disclosure for marketing purposes will require your authorization.
• Any use or disclosure that would constitute a sale of your information will require your authorization.

Your Other Rights Concerning Your Health Information Includes the Right to:

• See and get copies of your records. You may be charged a fee for the cost of copying your records.
• Request to have your records amended or corrected if you think there is a mistake. You must provide a reason for your request.
• Receive a list of disclosures. This list will not include the time that information was disclosed for treatment, payment or health care operations. The list will not include information provided to you or your family directly, or information that was sent with your authorization.
• Further restrict uses and disclosures of your health information. You must tell our office what information you want to limit and to whom you want the limits to apply. Our office is not required to agree to the restriction.
• Cancel authorizations previously provided by you to our office. This cancellation, however, will not affect any information that has already been shared.
• Receive a written notification in the event of a breach of your protected information.
• Choose how the program communicates with you in a certain way or at a certain place.
• Opt out of receiving fundraising communications.
• File a complaint if you do not agree with how our office has used or disclosed information about you.
• Receive a paper copy of this notice at any time.

ANY REQUEST YOU MAKE TO OUR OFFICE MUST BE IN WRITING How to Contact Our Office Regarding Your Privacy Rights:

Mail all written forms, requests and correspondence to:

Burleson Orthodontics & Pediatric Dentistry, Attn: Privacy Officer
4135 N Mulberry Drive Kansas City, MO 64116

The Privacy Officer may deny your request to look at, copy or change your records. If our office denies your requests, we will send you a letter that tells you why your request is being denied and if you can request a review of that denial.

How to File a Complaint:

You may file a complaint with our office or the U.S. Department of Health and Human Services-Office of Civil Rights: (You will not be retaliated against for filing a complaint)

Send correspondence to:
Burleson Orthodontics & Pediatric Dentistry, Attn: Privacy Officer
4135 N Mulberry Drive Kansas City, MO 64116

-OR-

Dept. of Health & Human Services 200 Independence Ave, SW
HHH Building Room 509H
Washington, D.C. 20201

For More Information:

If you have any questions about this notice or need more information, please contact the office Privacy Officer. Burleson Orthodontics & Pediatric Dentistry may change its Notice of Privacy Practices. Any changes will apply to information we already have, as well as any information we may get in the future. A copy of any new notice will be posted at our office as well as on our web site. You may ask for a copy of the current notice at any time, or get it on-line at www.BurlesonOrthodontics.com