Privacy Consent


Download a PDF of full information listed below.

Medical Consent

Consent: The undersigned hereby authorizes Dr. Mizrahi to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Dr. Mizrahi to make a thorough diagnosis of the patient’s orthodontic needs.

I also authorize Dr. Mizrahi to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctor chooses and employs such assistance as deemed fit to provide recommended treatment.

Permission To Release Health Information: I grant the right to the dentist to release health information obtained from me, and my dental treatment to third-party payors, and/or health practitioners. I understand that it is

my responsibility to advise your office of any changes in the information contained on this form.

Privacy Consent 

This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services. Prior to commencing your orthodontic treatment, you must review, sign and date this form.

Your protected health information, (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses and demographic data) may be used in connection with your treatment, payment or your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).

You have the right to review our office’s privacy notice prior to signing this Consent Form, a copy of which you may request along with this Consent Form.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend our office’s privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised notice.

You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.

Informed Consent 

A requirement facing all practitioners of medicine and dentistry is that the patient or the legal representative of the patient gives the practitioner informed consent. Informed consent indicates your awareness of the negative as well as the positive aspects of orthodontic treatment. This includes your understanding of the diagnosis, nature and purpose of proposed treatments, risks and consequences, treatment alternatives, and prognosis if there is no treatment.

You have my assurance that even though informed consent is legal requirement of all practitioners of medicine and dentistry I will endeavor to keep these negative possibilities of orthodontic treatment to a minimum.

Perfection may be our goal, but in dealing with problems of growth and development, genetics and environment, as well as patient cooperation, as we do in orthodontics, adequacy may be a necessary standard.

Teeth shift during the lifetime of any individual regardless of orthodontic treatment. With orthodontic treatment, there are changes in the positioning of the teeth following active treatment. Some patient’s front teeth tend to become slightly irregular during the late teens following orthodontic treatment - particularly if, at the onset of treatment, they are extremely crowded. I recommend that retainers are to be worn indefinitely following active treatment to prevent relapse (teeth shifting) in the future.

In certain instances, the enamel of some teeth can be affected by the protracted wearing of bands or bonded attachments in the presence of poor oral hygiene. This results in the decalcification or scarring of the enamel as evidenced by white or soft areas on the enamel. This can be minimized by the careful brushing of the braces and teeth as directed and the avoiding of taffy, caramel, and chewing gum which can enhance enamel dissolution.

On rare occasions, the nerve of a tooth can undergo regression and may become non-vital as a consequence of the pressure of orthodontic appliances or trauma to the tooth such as blows, falls, or being hit by an object.

At times a patient may have an existing periodontal condition that may prevent any possible orthodontic treatment. During orthodontic treatment, it is essential that good oral hygiene be maintained as the soft tissue gums may be more prone to inflammation and infection. If this were to occur, it may be necessary to refer the patient to the dentist for treatment and if the condition persisted, it may be necessary for the braces to be removed even though orthodontic treatment has not been completed.

At times it may be necessary for individuals with constricted arches to utilize a Rapid Palatal Split appliance. The intent of this appliance is to improve the bony relationships of the upper and lower jaw and the success depends upon the patient cooperation and age. There are many times when there may be a relapse and full cooperation is not possible.

A small percentage of non-orthodontic patients show evidence of root resorption (decrease in the size of root surface or root length or changes in shape) of some teeth. The incidence of root resorption is increased amongst patients undergoing orthodontic treatment and is considered a scar of treatment. Root resorption in the great majority of orthodontic patients does not jeopardize the health, function, longevity, or appearance of the tooth or teeth. In a very few patients, and the occurrence is rare and statistically insignificant, root resorption of over one-third the length of the root can occur. This substantial decrease in the size of the root can cause a dental problem requiring other dental procedures, and in extreme cases can result in tooth loss. It must be remembered that this unusual decrease can occur in individuals that have never been treated by an orthodontist.

In some instances, and here again the incidence is infrequent, the patient presents at the onset or during treatment or at the conclusion of treatment some problems with the joint of the lower jaw. This is manifest by “clicking” or pain in the joint upon opening or closing of the jaws. These symptoms can also be present in individuals who are not undergoing orthodontic treatment. Problems of the so-called “temporal mandibular joint” known as “temporal mandibular dysfunction” are an enigma to practitioners of dentistry and the resolution of this problem, at this time, is not assured.

I consent to the taking of photographs and x-rays before during and after treatment, and to the use of them by the doctor in scientific papers or demonstrations. I certify that I have read or have had read to me the contents of this form and do realize the risk and limitations involved, and do consent to orthodontic treatment. No practitioner of medicine or dentistry can guarantee any result but can only indicate that they will attempt to resolve the particular problem. To this end, you have my assurance.

Forest Hills Orthodontic Associates
110-35 Jewel Ave
Forest Hills, NY 11375
Phone: 347-384-8562
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