Patient Forms


If you are a new patient to our office, the attached file contains our new patient bundle with forms that will need to be filled out when you arrive at our office.  Printing them, filling them out and bringing them with you will allow us to attend to your medical needs more quickly than completing them on your arrival.  Thank you and please call our office if you have any questions at all.

Patient Forms







PATIENT’S NAME__________________________________

SINGLE_____ MARRIED_____ OTHER__________

BIRTH DATE____________ AGE______



CITY_________________________ZIP_________________ PHONE__________________


EMPLOYED BY_______________________________________ OCCUPATION_______________________________________

 BUS. PH._______________


                                                                                                          IF PATIENT IS A MINOR


FATHERS NAME____________________________________



 EMPLOYED BY_________________________________________


BUS. PH.________________






 EMPLOYED BY_______________________________________ OCCUPATION______________________________________

BUS. PH.________________



TYPE OF INSURANCE_______________________________________________________ PHONE# _______________________________


INSURANCE ID #_________________________________________________ PLAN/GROUP #___________________________________________

NAME OF POLICYHOLDER________________________________________ DATE OF BIRTH________________ SS#______________________


2ND INSURANCE_______________________________________________________ PHONE# ______________________________

INSURANCE ID #_________________________________________________ PLAN/GROUP #___________________________________________

NAME OF POLICYHOLDER________________________________________ DATE OF BIRTH________________ SS#______________________


NAME OF YOUR DENTIST___________________________________________

NAME OF YOUR PHYSICIAN____________________________________


WHOM MAY WE THANK FOR REFERRING YOU TO US?________________________________________________________________PLEASE MAKE ANY COMMENTS THAT MAY AID US IN HELPING YOU.



                                                                                               THANK YOU


                Craig K. Mathias, D.D.S., M.S., Practice Limited To Orthodontics, Member Of The American Association Of Orthodontics










For Patient: _____________________________________________________


As a rule, positive orthodontic results can be achieved by informed and cooperative patients. Thus the following information is routinely supplied to all who consider orthodontic treatment. While recognizing the benefits of healthy teeth and a pleasing smile, you should also be aware that orthodontic treatment has limitations and potential risks. These are seldom enough to avoid treatment, but should be considered in making the decision to undergo orthodontic treatment. Orthodontic treatment usually proceeds as planned; however, like all areas of the healing arts, response to treatment and results cannot be guaranteed.




Orthodontics plays an important role in improving overall oral health.  Orthodontics also helps create balance and harmony between the teeth and face for a beautiful, healthy smile.  An attractive smile enhances one’s self esteem, which may actually improve the quality of life itself. Properly aligned teeth are easier to brush, and thereby may decrease the tendency to decay, or to develop diseases of the gum and supporting bone.


Because of the individual conditions present and the limitations of treatment imposed by nature, each specific benefit may not be attainable for every patient. The unknown factor in any orthodontic correction is the treatment response and cooperation of the patient during orthodontic treatment.




Orthodontics strives to improve the bite by helping to direct forces placed on the teeth.  This protects the teeth from trauma during ordinary everyday activities, such as chewing stress.   Properly aligned teeth also help minimize excessive stress on bones, roots, gum tissues and the temporomandibular joints.  Orthodontic treatment has the potential to eliminate future dental problems including the problem of abnormal wear. Treatment can facilitate good oral hygiene to minimize decay and future periodontal problems.  In addition, orthodontics can provide a pleasant smile, which may enhance one’s self-image.




All forms of medical and dental treatment, including orthodontics, have some risks and limitations. Fortunately, in orthodontics complications are infrequent and when they do occur they are usually of minor consequence. Nevertheless, they should be considered when making the decision to undergo orthodontic treatment. The major risks involved in orthodontic treatment may include, but are not limited to:


1. DECALCIFICATION: (Permanent enamel markings) Tooth decay, gum disease, and permanent markings (decalcification) on the teeth can occur if orthodontic patients eat foods containing excessive sugar and/or do not brush their teeth frequently and property. These same problems can occur without orthodontic treatment, but the risk is greater to an individual wearing braces.


2. ROOT SHORTENING: In some patients the length of the roots may be shortened during orthodontic treatment. Some patients are prone to this happening, some are not. Usually this does not have significant consequences, but on occasion it may become a threat to the longevity of the teeth involved.


3. GOOD ORAL HYGIENE: The health of the bone and gums which support the teeth may be affected by orthodontic tooth movement if a condition already exists, and in some rare cases where a condition does not appear to exist. In general, orthodontic treatment lessens the possibility of tooth loss or gum infection due to misalignment of the teeth or jaws. Inflammation of the gums and loss of supporting bone can occur if bacterial plaque is not removed daily with good oral hygiene.


4. RELAPSE TENDENCY: Teeth may have a tendency to change their positions after orthodontic treatment. This usually is only a minor change and faithful wearing of retainers as instructed should help reduce this tendency. Throughout life the bite can change adversely from various causes, such as: eruption of wisdom teeth, growth and/or maturational changes, mouth breathing, playing of musical instruments and other oral habits, all of which may be out of the control of the orthodontist.


5. JAW JOINT PROBLEMS: Occasionally problems may occur in the jaw joints, i.e., temporomandibular joints (TMJ), causing joint pain, headaches or ear problems. These problems may occur with or without orthodontic treatment. Any of the above-noted symptoms should be promptly reported to the orthodontist.


6. LOSS OF TOOTH VITALITY: Sometimes a tooth may have been traumatized by a previous accident or a tooth may have large fillings, which can cause damage to the nerve of the tooth. Orthodontic tooth movement may in some cases aggravate this condition and in rare instances may lead to root canal treatment.


7. POST-ADJUSTMENT PAIN: Sometimes orthodontic appliances may accidentally be swallowed or aspirated or may irritate or damage oral tissues. The gums, cheeks and lips may be scratched or irritated by loose or broken appliances or by traumatic blows to the mouth. Usual post adjustment tenderness should be expected, and the period of tenderness or sensitivity varies with each patient and the procedure performed. Typical post-adjustment tenderness may last 24 to 48 hours. You should inform our office of any unusual symptoms, broken or loose appliances, as soon as they are noted.


8. MINOR INJURIES: On rare occasions, when dental instruments are used in the mouth, the patient may inadvertently get scratched, enamel abrasions, poked or receive a blow to a tooth with potential damage to or soreness of affected oral structures. Abnormal wear of tooth structures is also possible if the patient grinds their teeth excessively. We will use extreme care to avoid minor injuries.


9. HEADGEAR INSTRUCTIONS: (If headgear is necessary) Improperly handled, headgear may cause injury to the face or eyes, even blindness. There have been a few reports of injury to the eyes of patients wearing headgear. Patients are warned not to wear the appliance during times of horseplay or competitive activity. Although our headgears are equipped with a safety system, we urge caution at all times.


10. ADJUNCTIVE SURGERY: Sometimes oral surgery; tooth removal or orthodontic surgery, is necessary in conjunction with orthodontic treatment, especially to correct crowding or severe jaw imbalances. Risks involved with treatment and anesthesia should be discussed with your general dentist or oral surgeon before making your decision to proceed with this procedure.


11. UNFAVORABLE GROWTH: Atypical formation of teeth, or insufficient or abnormal changes in the growth of the jaws may limit our ability to achieve the desired result. If growth becomes disproportionate during or after treatment, or a tooth forms very late, the bite may change, requiring additional treatments or, in some cases, oral surgery. Growth disharmony and unusual tooth formations are biological processes beyond the orthodontist’s control. Growth changes that occur after orthodontic treatment may alter the quality of treatment results.


12. TREATMENT TlME: The total time required to complete treatment may exceed the original estimate. Excessive or deficient bone growth, poor cooperation in wearing the appliance(s) the required hours per day, poor oral hygiene, broken appliances and missed appointments can lengthen the treatment time and affect the quality of the end results.


13. CERAMIC BRACES: When clear and tooth colored brackets (ceramics) have been utilized, there have been some reported incidents of patients experiencing bracket breakage and/or damage to teeth, including attrition and enamel flaking or fracturing on debonding. Fractured brackets may result in ceramic remnants, which might be harmful to the patient especially if swallowed or aspirated.


14. ADJUNCTIVE DENTAL CARE: Due to the wide variation in the size and shape of teeth, achievement of the most ideal result (for example, complete closure of excessive space) may require restorative dental treatment (in addition to orthodontic care). The most common types of treatment are cosmetic bonding, crown and bridge restorative dental care and/or periodontal therapy. You are encouraged to ask questions regarding dental and medical care adjunctive to orthodontic treatment of those doctors who provide these services. (i.e. general dentist, periodontist, oral surgeon).


15. MEDICAL PROBLEMS: General medical problems can affect orthodontic treatment. You should keep your orthodontist informed of any changes in your medical health.


16. PERFECTION IS OUR GOAL: In dealing with human beings and problems of growth and development, genetics and patient cooperation, achieving perfection is not always possible. Orthodontics is an art, not an exact science; therefore, a functionally and esthetically adequate result, not 100% perfection, must be acceptable. Your comments in regard to your expectations prior to, during and after orthodontic treatment will help us understand your concerns. Please keep us regularly informed of your feelings, concerns and results that do not meet your expectations.




For the vast majority of patients, orthodontic treatment is an elective procedure. One possible alternative to orthodontic treatment is no treatment at all. You could choose to accept your present oral condition. The specific alternative to the orthodontic treatment of any particular patient depends on the nature of the individual’s teeth, supporting structures and appearance. Alternatives could include:


1. Extraction versus treatment without extraction(s);

2. Orthodontic surgery versus treatment without orthodontic surgery;

3. Possible prosthetic solutions (bridges, implants, partials, replacement teeth); and

4. Possible compromised approaches (To be discussed with you, if applicable)





























Doctor Mathias and/or his staff have presented information to aid in the decision-making process.  I (We) have been given the opportunity to ask the doctor and/or staff members all questions I (We) have about the proposed orthodontic treatment.   I (We) hereby acknowledge that the major treatment consideration and potential risks of orthodontic treatment have been explained and presented to me (us).  I (We) have read and understand both sides of this consent form.  I (We) also understand that problems listed may or may not occur during orthodontic treatment.  I (we) give our consent for Doctor Mathias and his staff to perform routine orthodontic care.  I (we) also give Doctor Mathias and his staff authorization to release patient information to other healthcare providers, insurance companies and other involved parties as deemed appropriate by our office



Patient / Parent (s): X _________________________ X _________________________ Date:  _________




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