OJW

FORMS

OJW Forms (ver. 052621)

 

1. Informed Consent 

2. Med-Dent History 

3. Fee-Payment-Service information.

4. Self-assessing whether OJW is right for you  

5. List of problematic candidates for OJW.

OJW is most suitable for patients with CEEP (Compulsive Emotional Eating Problems) who would never consider invasive gastric surgical procedures or never take over-the counter or physician-prescribed weight-control medications.

Ted Rothstein DDS PhD
Life-Active AAO Member: Retired from active practice Orthodontics
Inventor of and Specialist in OJW™ (video):
Orthodontic Jaw Wiring: Read about

OJWforweightcontrol.com
drted35@gmail.com   iPhone. 718 808 2656  

 Brooklyn NY and Salem OR

 1. Informed Consent for OJW

Note: the underlined are links; click to view
 

DIRECTIONS

Copy and paste into the document it came in. Email to  drted35@gmail.com

Be certain you have signed/initialled in all the spaces and sections requested.

 

Please join OJW Patients, a private Facebook group 

https://www.facebook.com/groups/628899403877919/

 

Copy and Paste this entire document in the Email it came in. This page includes ALL Five documents listed above. Carefully read the Informed Consent.  I will review all and call to let you know whether you are an acceptable candidate.

 

* Date:    /    / 2021-22       * Name:                         * Age:     Date of birth:         * Height:
* Present Weight:                               * Goal Weight:          

   (click on link)—>*Present Body Mass Index (BMI):
* Activity Level  (Life style): (Circle one) inactive, mildly a., moderately a., very active  
*Number of months you will dedicate passionately to follow the protocol (55-LCLD) of the OJW approach to weight loss:  2 3 4 5 6 (3 months/ 25-30 pounds, assuming 5 pounds first week then 1.5 pounds each week thereafter)
*Address:                        *City:              *State:       * Zip:


*Occupation:
*Home Telephone:                 *and Work Telephone (Other):                 * and Cell/ Mobile Telephone:
 

*Email Address: Dr. Ted will not contact you if you do not provide this item. 
 

* Your dentist’s name:
Address:
* Telephone number:
I give Dr. Ted my permission to call my dentist by placing my initials here_______.
*You physician’s name:
Address:
*Telephone number:
* I give Dr. Ted my permission to call my physician by placing my initials here_______.
* OJW preferred appointment date:________ ** Alternative OJW appointment date:__________  or “Date undecided”

 

I, _________________________, authorize Dr. Rothstein to wire my jaws into the OJW position of physiologic rest ††. I realize I will need to scrupulously follow the 55-LCLD OJW weight-loss Protocol.*  I know I can have the  orthodontic jaw wiring (brackets and wire) removed at any time I request. I have read and I understand all the material on Dr. Rothstein’s website related to the orthodontic jaw wiring procedure. I also recognize that even if I achieve my weight loss goal, I may well regain the weight. I have been advised that the best way to maintain the weight loss is by means of life style changes, which include a low calorie, balanced diet matched to an appropriate exercise regime for my life style (see also document: weight control maintenance tips.)
 

I understand that Dr. Rothstein requires a note from a physician (or proxy care provider) indicating: “You may begin a long-term, low-calorie liquid diet.”. The purpose of such a note is to rule out for your own safety and my assurance that such a diet would not be harmful to you. Such a release is taken to mean that you have no gastro-intestinal issues or other medical problems that would harm you by beginning such a diet. Lacking this medical release note the OJW service may not be provided.
 

I understand that  OJW requires that braces (brackets) be bonded to my teeth; that braces may sometimes become detached and need to be rebonded. Moreover, I realize that if I come from out-of-state and a bracket detaches, I will need to see a local orthodontist to have the bracket(s) rebonded at an additional cost to me.

 

Whether you are in OJW or not some people unconsciously  habitually  gnash/grind/ their teeth during the day, and some during the day and when they sleep.  It can be very harmful to your teeth and TMJ and cause multiple detached brackets:  See Google images:  http://bit.ly/3a2Cif4   Dr. Rothstein will rebond up to five detached brackets at no charge if you can return to the office.  Otherwise, he will help you locate a nearby orthodontist willing to do it at a fee.  One should inquire what the fee is in advance.

Finally, that at present there are few if any orthodontists who will rewire me and for that reason I have elected  to rewire myself (or have my significant other do the rewiring for me following the method Dr. Rothstein taught me when the OJW was placed.

I understand that substituting elastics for the wires can cause traction on my teeth and result in my teeth elongating and consequently causing harm to my bite.

Since I may come from out-of-state and may not be able to return to Dr. Rothstein’s office to have my OJW brackets removed, I will need to locate a local orthodontist whose fee may range from $300- $400+  to remove the OJW brackets and adhesive.

I am at liberty to review the results of the survey Dr. Rothstein completed in January of 2009 to see how other OJW patients fared.  View the benefits and problems of OJW (as an Excel spread sheet) and to read  his manuscript on the nature of the OJW service as provided by dental professionals: Orthodontic Jaw Wiring: The Dental Professional’s Role in Weight Control for Compulsive Overeating Leading to Obesity  

Dr. Rothstein’s work shall be largely limited to placement/fitting and removal of the orthodontic jaw wiring appliance as a whole, periodic rewiring and tooth cleaning of the inside of my teeth, replacement of any accidentally detached brackets and finally, warning me if he thinks that continued use of the orthodontic jaw wiring is causing/may cause harm to my gums, teeth and jaw joints.

The OJW appointment will include an oral and a TMJ  examination and possibly a panoramic X-ray if warranted and detailed instructions how to place and remove the OJW wiring. I understand that I must remove the wires at the end of five weeks and return to the office (not applicable to out-of-town patients) to have Dr. Rothstein re-examine me to ascertain that my teeth, gums and jaw joints (TMJ) are in healthy condition. Above all, I understand that he will not rewire me if I cannot pass the three-finger mouth opening test  without difficulty or discomfort. Finally, that Dr. Rothstein will provide me with the prerequisite instruments needed to place and remove the wiring.


I am fully aware that other methods of weight loss are available to me including: weight loss medicines such as Alli, Meridia  Xenical, “Qysymia” formerly Qnexa, Belviq, Weight Watcher’s and Jenny Craig programs and a variety of bariatric surgical techniques. I am also aware of such organizations asOvereaters anonymous and Greysheeters anonymous (GSA) for compulsive overeaters.

I understand I am required to make a new appointment for between 4 and 6 weeks after each time Dr. Rothstein rewires my jaws and I realize that I must release the wire {See Release methods} 4-6 days prior to that to permit me to exercise my jaw muscles.  [See jaw joint exercises] I realize that if I do not adhere to eat a soft diet during the times my jaw is unwired I may cause brackets to become detached.


I have been advised that if I have any conditions which are medically compromising and that demand special medical attention to dietary details such as, to mention just a few: diabetes, gastric reflux, Crohn’s disease, irritable bowel syndrome and malabsorption syndrome, I should not have this procedure done. I have had a medical exam in the recent past and I am in good health and I have no medical problems that may interfere with or be at odds with this procedure. My physician has not advised me to forgo this procedure.

 

I have read all the  FAQ’s related to OJW and I have especially read the question ,  “Who is NOT a good candidate for the OJW procedure.”   I realize the list of reasons for not being a good candidate does not cover every possible condition of ill health.  I am confirming that I am a good candidate and I am providing my initials as acknowledgment in this space _________.

 

There is also the possibility that I might be allergic to metal components in the brackets/wire such as Nickel (Get Information about Nickel allergy)  or even the adhesive used to bond the brackets to the teeth any of which might require having to have the OJW removed. This caveat extends to any of the components of the 3D bracket used in OJW Ultralite.

 

I have been advised that prior to orthodontic jaw wiring I should have a complete physical exam including a complete blood study, and an analysis of my present caloric intake by a registered dietitian [Find a registered dietician in the American Dietitian's Association]  so that a liquid diet can be designed for my  body type and activity level that is compatible with my weight loss goals.** I realize that while Dr. Rothstein may try to help me with the liquid diet suggestions that it will be my total responsibility to create a liquid diet compatible with my goals.
 

I agree to keep an accurate daily log of my liquid diet showing the calories in each meal and the total of my daily and weekly intake. I agree to show Dr. Rothstein this log at each office appointment. I realize that I may not reach my weight loss goal, but I do not hold Dr. Rothstein responsible since he has not made any guarantee regarding the success of attaining my goal. I realize that exercise is a very important factor in losing weight and that Dr. Rothstein will/has apprise(d) me of the relationship between weight loss and gain and the number of calories and activities I do. [See Dr. Ted's exercise].

 

I realize that extensive vomiting could result in vomitus being taken into my airway, which could be a very serious medical problem requiring immediate medical attention. Consequently, I realize I should immediately remove the wires that hold my teeth together under conditions of suspected or impending nausea. [Read special note from highly respected teacher, educator and practitioner] Dr. Rothstein will/has also show(n) me how to remove the wiring with a  cuticle scissor and even a fork. I have been advised to carry at all times wire removing instrumentsr that Dr. Rothstein gave me.  Dr. Rothstein has told/shown me how to remove the wire in an emergency with a simple fork and shown me that it can be easily accomplished in less than 10 seconds. [SEE INSTRUMENTS AND METHODS OF REMOVING THE WIRE.]  Dr. Rothstein has/will give(n) me his home phone with special instructions to call him if I ever have any problems related to this procedure outside of regular office hours. 


I acknowledge by my signature here ____________________ that I understand the above.

I have been told that my speech may be somewhat impaired, that Listerine rinses will be the only way to keep the insides of my teeth and mouth clean. I have been told to avoid and/or report any gnashing/bruxing or sideways grinding of my teeth or any jaw muscle aches since they can cause problems to my teeth and jaw joints.

Dr. Rothstein has prepared me for the uncommon possibility of “panic attack” upon being wired and that I may have to release/remove  the wiring immediately or within a few days from the OJW appointment  because I find that I am unable to adapt to/tolerate my jaws wired in the “OJW position of physiologic rest Or, or I may find the orthodontic brackets and wiring themselves are feeling “foreign”/uncomfortable to me.††

Consequently, I understand there will  be an initial trial period when the OJW is first placed when I will have to adapt to novel situation that I have never experienced before. I understand that Dr. Rothstein will remove the OJW Immediately if requested, or rewire me when I am ready for it (at no additional charge as long as the brackets are still in place. [Read D.V.'s experience.]

I understand that if I pay the fee prior to the OJW appointment and then decide that I do not want to proceed with the OJW that Dr. Rothstein will refund all of the fee I paid except a service fee of $375.

I understand that the OJW placement  is non-refundable following insertion/placement of the OJW and that the removal of the wiring and all braces and final cleaning at the last visit is included in the fee. However, for those OJW patients from out-of-state who can not return to my office to have their  OJW brackets removed, Dr. Rothstein will assist you in locating an orthodontist as close as possible to your home who will remove the 12 brackets (one minute or less)  and the adhesive (about 5 minutes).  The fee may vary from $75 -175 so do confirm the fee before having the local orthodontist perform the OJW removal.

Finally, I permit Dr. Rothstein, if he chooses, to show the chart entries of my case on his website in the “orthodontic jaw wiring for weight loss section.” I realize he will respect my right to anonymity. And, I authorize Dr. Rothstein to share my records with other dental, medical and related healthcare professionals concerned with helping the overweight control their problem as part his goal to further the gathering of knowledge about OJW (which is still an experimental method for weight control in obesity) into a national database.
 

OJW has not as yet been submitted to the FDA for its approval.  Dr. Rothstein has provided OJW to 150+ patients. A utility patent application was submitted to the USPTO and an application to was submitted to the USPTO to register the mark “OJW” and OJW®: Weight-control was approved as a registered trade mark for Orthodontic Jaw Wiring for weight control/loss.

 

Readers are urged to read Dr. Rothstein’s paper on OJW as a Treatment Modality for Binge Eaters [Click here].


I have read the Informed Consent above including the hyperlinks directing me to supporting educational material. I fully understand the OJW service that Dr. Rothstein is going to provide me with. My signature acknowledges my consent for Dr. Rothstein to provide me with the OJW appliance:
 
PATIENT’S SIGNATURE:_________________DATE:____________

Supplemental paragraph in the OJW Informed Consent for use of clear transparent 3D-printed brackets in lieu of traditional metal (OJW: Ultralite)

If I choose to have some, if not all clear-transparent 3D-printed brackets placed on my teeth in lieu of the typical metal brackets Dr. Rothstein uses, I realize I am one of the early patients to have this new type of bracket placed on my teeth. In addition to the new bracket type, Dr. Rothstein will be using wire almost half as thin as the wire now in use with standard brackets. He calls this technique OJW: Ultralite.  The utility of the technique has been tested on himself alone.

 

I am aware that some variations of the size, form and position of the teeth he places them on may cause the adjacent skin be irritated, requiring me to use orthodontic wax to cover the offending part.  In some instances, they may have to be repositioned or replaced with metal which may necessitate finding a local dental professional to accomplish at additional fees. Dr. Rothstein has informed me that the 3D bracket is in the Beta (Testing Phase) and he is in the process of learning the new characteristics of this OJW bracket such as taste, texture, comfort, strength, cohesion to the teeth and ease of wiring. His initial assessment is they add no more risk to OJW than with using metal.  Dr Rothstein has made me aware the 3D brackets may lose their clarity/discolor over an unknown period of time due to such factors as coffee, tea, smoking and the acid-base balance of my normal oral fluids like saliva. Over the period of time they are in my mouth, he will do his best to solve any problems arising from having them placed on my teeth in the same manner as noted in the "Troubleshooting OJW Problems" document that has provided me with. 

I have read and understand this supplement to the Informed Consent.  Ver. 052621

 

PATIENT’S SIGNATURE:_________________DATE:____________

 

The Position of the patient's Jaw in Orthodontic Jaw Wiring for Weight-control:

 

The position is called "Rothstein's OJW position of Mandibular Weightlessness" (ROPMW). It corresponds closely to the “normal” Physiologic rest position. The wiring's sole function is to limit the extent of mouth opening beyond the rest position. Consequently, the lower jaw is suspended naturally by the jaw muscles—not by the wiring. Thus, the wires never exert any vertical (extrusive) forces on the teeth and therefore cannot alter the patient’s occlusion (bite). Nevertheless, the patient can speak perfectly clearly, but, is unable to ingest the solid foods we know as “junk/comfort” food, known in excess to cause obesity.  The TMJ jaw joint never suffers any stiffening since the jaw’s position is “natural”. The protocol nevertheless calls for Five days of being unwired after Five weeks of being in the OJW position of Weightlessness.

 

 

2. Medical-Dental History Form for OJW Patients

(Some questions are purposefully redundant)

How were you referred to Dr. Rothstein?

What research have you done to familiarize yourself with OJW?

If you are deemed to be a good OJW patient do you think you will be dedicated and passionate enough to following the prescribed OJW protocol 55-LCLD   Briefly why?

Are you comfortable beginning a long-term low-calorie liquid diet?

Do you have any health issues?   Y     N. If Y how would you describe your health issue?

Does your career require the use of your mouth?   Y   N     If Y in what way?

Do you know what a panic attack is?

Are you planning in the near future to have any Dental work? Y….N   If Y what kind of work?

Do you wear any REMOVABLE dental devices?

Do you have any missing teeth on the SIDES? If YES describe how many: UpperRight___UpperLeft____LowerRight____LowerLeft

Do you have any Medical or Dental problems?  Y     N

Are you now under the care of a dentist or physician or psychologist or psychiatrist?  Y   N

Are you allergic to latex examination gloves?  Y     N

List all your allergies past and present:

Have you ever been hospitalized?  Y    N   If Y please explain:

Do you now have any Dental Problems?  Y     N… If Y please explain:

Do you now have any Medical Problems?  Y    N   If Y please explain.

Do you now have any Physical problems?  Y     N   If Y please explain.

Do you now have any Psychological problems?   Y…..N   If Y please explain.

Do you have any speech problems?

Do you have any neck problems?  If Y please describe.

Do you currently have pain in your face, head, neck, face, jaws or teeth:  Y     N   If Y please explain.

Do you wake up with sore teeth or jaws?

Have you been told you snore?  Y    N

Do have any jaw joint problems that cause clicking. popping, or locking when chewing?

Do you chew gum?  Y….  How frequently?

Do you have any respiratory problems?  Y     N If Y please explain:

List all the medications you take on a regular basis:

If you take medications are any of them LARGE pills or capsules?

How often do you have colds?

Do you clench your teeth during the day?

Do you grind you teeth when you sleep?

When was the last time you visited your dentist?_____ For what purpose?

Who have you spoken with about having OJW:   None, Friend, Family, Dentist, Physician, Dietitian, Psychotherapist, Bariatric Surgeon, Spouse, Some other not in the list _________

What did you learn from them?

Will you have the support of your Spouse, Friends or Family if you undertake OJW?

Do you get anxious easily?

Are you taking any medications for anxiety now?  Y    N   If Y Please name the Med.____________

Have you ever been treated for Anorexia?  Y   N.  If Y, How long ago?

Attestation: The information I have provide above is accurate and truthful to the best of my knowledge

 

PATIENT’S SIGNATURE:_________________DATE:____________

 

 

3. Financial Information for OJW: Weight-Control

 

Effective May 5, 2021 the fee for OJW: Weight-Control may change from time-to-time. In general if you are quoted a fee it will likely be honored. Except under rare circumstances once the fitting appointment is completed no refund requests are accepted.

 

The fee covers:

  • Fitting/Placing the OJW: Weight-Control appliance; Teaching you to Remove and Rewire yourself.

  • 24/7 Commitment to help you succeed reaching your “Goal Weight” and helping you maintain it.

  • Documents to help you navigate the OJW experience start to finish.

  • Removing the OJW Brackets. Or helping you find an Orthodontist who will at additional fees.

 

METHODS OF PAYMENT ACCEPTED: 

Prior to the fitting appointment: Paypal, Venmo, Personal checks, Credit cards: At the fitting appointment:  Certified bank check, USPS money order, Cash.

INSURANCE COVERAGE :-( 

There is no Insurance coverage for this Conservative, Non-invasive method of weight control. It is most suitable for patients with CEEP (Compulsive Emotional Eating Problems) who would never consider invasive gastric surgical procedures or never take over-the counter or physician-prescribed weight-control medications. While overweight (obesity) is classified per se as a disease (with multiple health consequences), “OJW for weight loss/control: has not been granted a “treatment code”. Consequently, there are no insurance benefits:  Please inquire with your health plan.  I would be delighted to be mistaken in regards to my knowledge of the currency of my information.

  

CONDITIONS OF INITIAL PAYMENT:

$500 is due upon scheduling you for your OJW fitting  appointment.: The payment will be applied to the total fee. The initial payment is non refundable, however, if you are unable to keep your appointment, it will be applied to the fee due when you reschedule your OJW: Weight-Control appointment. The balance is due at the fitting appointment.

 

PATIENT’S SIGNATURE:_________________DATE:____________

 

4. Self-assess whether OJW Weight-Control is right for you

Please join  OJW Patients a private Facebook group:

https://www.facebook.com/groups/628899403877919/

Self-Assessing whether you will be passionate and dedicated in undertaking OJW: Weight-control:

Please put a check mark next to the indicator that applies to you and return with your Informed Consent and Medical-Dental Form.

 

Please add any other assessment items that may be impacting YOU.*

  • You have been thinking about starting diet for the past year/ number of months

  • You look in the mirror and that makes you unhappy.

  • You finally weighed yourself and were aghast.

  • You’re sick and tired of your doctor, friends and relatives telling you to “just get control of yourself and eat right”.

  • Nobody seems to understand the burden/seriousness of the problem of eating compulsively.

  • You can easily master rewiring yourself (See wiring video https://youtu.be/_cR2h8latyE and rewiring video: https://youtu.be/bfd6fDG0DrA ;OJW: Ultralite rewiring video: https://www.youtube.com/watch?v=ObOP2TC7sig&t=137s)

  • You refuse to weigh yourself.

  • You know full well you are not exercising enough.

  • You “feel” overweight.

  • Your friend poked a finger in your belly and said nothing.

  • Your kid said “You look “the F-word”.

  • Your friend recently exclaimed that they are beginning a diet and they “looked good” to you.

  • You were having lunch with a friend and they we’re having a salad-you noticed.

  • Summer is getting closer.

  • Your clothes have become ill-fitting

  • You can’t afford new clothes.

  • Your look with envy at thin people passing by you.

  • Your boy/girl-friend actually said you look the F-word or “the O-word”.

  • You woke up one recent morning and simply acknowledge to yourself that you are overweight.

  • You looked at the wrapper of a candy bar, noted that it had 400 calories, and then thought twice before you bought it, but you did, and ate it and then felt guilty.

  • You know your diet is excessively rich in Carbohydrates: bread, cake, cookies

  • You’re eating when you’re not hungry.

  • You’re eating “compulsively”: You think you have CEEP—Compulsive- Emotional Eating Problems.

  • Eating is replacing some aspect of your life that is missing.

  • You have a “sweet-tooth”.

  • You have not had much success with other diets.

  • You would never consider surgery.

  • You believe appetite suppressing medications are dangerous.

  • You are good with idea that Dentists are professionals who can help with weight-control problems.

  • You’re not being aware of the calories in the foods you’re ingesting.

  • You’re not being discriminating regarding the size of the portions you take to eat.

  • You are paying more and more attention to TV ads promoting weight control methods.

  • Your doctor suggested a diet would be beneficial for your health.

  • Your mother/father/older sister/brother made a remark suggesting you need to lose some weight.

  • You realized recently you weight more than you did last year.

  • You find yourself standing in front of the refrigerator/cookie jar at 2am.

  • You’ve just been diagnosed with Type 2 Diabetes.

  • You found out about “BMI” as an indicator of excessive weight and yours is between 27and 38.

  • You believe that OJW®: Weight-control may give you the assist that will break the impasse you’re at now.

  • Your blood pressure has been rising over the past year in tandem with your weight.

  • As soon as you get anxious you go to the refrigerator to your friends that never reject you.

  • You keep buying Junk-Comfort food: Whip cream, Peanut butter, Candy bars

  • You’re feeling depressed.

  • Your face is starting to look jowly to you.

  • You see a double chin and that bothers you.

  • Your face is looking pudgy to you.

  • Men: When you look down in the shower you can’t see it.

  • Woman: when you look down you look pregnant.

  • You’re binge eating.

  • You have tried other diet methods and now you think OJW might be helpful.

  • You like to juice and OJW depends on you doing that.

  • You are having more than the usual difficulty climbing steps and walking up hill.

  • You are not looking at the labels of the foods you buy: Calories,Carbs, Fat, and Cholesterol etc.

  • You’re drinking sugared soda.

  • You’re not buying reduced-fat foods.

  • You’re drinking loads of alcoholic drinks

  • You’re drinking too much fruit juices.

  • You’re using cannabis and succumbing to the munchies.

  • You have become less and less active.

See Also Below : “Who is not a good candidate for OJW”:

*Please add any other assessment items that are impacting YOU.

 

Note:

Dr. Rothstein invented OJW and provides OJW®: Weight-control in Brooklyn NY and Salem Oregon--an hour from where he lives in Portland. He teaches this service to Dental Professionals. Feel free to have your Dentist/Physician/ Dietitian contact him for further information. Contact: drted35@gmail.com; (718) 808-2656: ojwforweightcontrol.com

 

5. Who is not a good candidate for OJW

Answer: Your mouth has many functions both obvious (talking) and not so obvious (sneezing) and is therefore the source of many pleasurable activities. The loss of any of them may provoke anxiety. Therefore one should think carefully about undertaking this method of weight control.

A partial list of poor candidates for OJW would include:

a. Persons who need to floss their teeth due to gum problems or other compulsive reasons.

b. Persons who speak abundantly for business or other reasons whose speech might be rendered less than perfectly clear because of being wired closed.

c. Persons whose sex life would be rendered intolerable if intimate oral functions were impaired even a little.

d. Persons with multiple-missing, loose or decayed teeth

e. persons wearing removable prosthetic appliances

f. Those with psychological or emotional disorders who might feel powerless/ panicky with their mouths wired closed.

g. Those whose work functions might be impaired such as an actor, singer, waiter, teacher etc.

h. Persons with systemic diseases such as diabetics whose diets could not accommodate a liquid diet.

i. Persons who cannot breathe through their nose and whose breathing might be compromised by being held continuously in a closed bite teeth position.

j. Those who are highly allergic are more at risk.

k. Persons who have respiratory ailments such as snoring and/or sleep apnea as well as those who must use use a broncho-dilator spray such as asthmatics.

l. Persons who have a history of Temporo-Mandibular Joint dysfunction (TMJ). Learn more about the TMJ: [Information source number 1].

m. Persons who are taking oral pill/capsule form medications could encounter some difficulties trying to pass a large capsule into the mouth behind the last teeth. It would be virtually impossible if the wisdom teeth were fully in place.

n. Persons who compulsively clench/brux/gnash their teeth.

o. Persons who have, or are suspected of having, anorexia or bulemia to begin with.

p. Persons with frank unresolved periodontal (gum-tooth socket) problems.
q. Persons who drink alcoholic beverages. (Alcohol suppresses the gag reflex). In the event of alcoholic intoxication vomiting can occur. [See note from respected oral-surgeon/orthodontist educator.]    
r. Persons who 1. will not provide a telephone number 2. do not have an Email address. 3. below the age of 21 unless accompanied by a parent. 4. are NOT more than 125 pounds overweight or less than 25 pounds overweight (i.e moderately obese and obese, but not "morbidly" obese).

s. Persons who are unwilling/unable to complete all parts of this form accurately and timely.

t. Persons who will not join "OJW Patients" my private Facebook page

Initials___________ Date: _______________