DIRECTIONS:
Carefully read the Informed Consent then fill in the data requested (* information requested is mandatory). Place your initials/name in all places requested and email the Informed Consent to drted35@aol.com. Then just below see hyperlinks to the "Adult Acquaintance" and  "Adult Medical History" forms. Download and complete BOTH  forms and mail or fax them  to the office (fax 718 852 1894 evening best).  When I have received ALL THREE FORMS  I will call you without further delay. With care, Dr. Ted Rothstein.

* Date:    /    / 2005 6 7       * 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 are initially willing to dedicate passionately to the jaw wiring (OJW) approach to weight loss:  2 3 4 5 6 (3 months/ 21 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_______.
 

Please complete both forms indicated below and FAX to my office: 718 852 1894.  After I review the data from ALL THREE FORMS I will call you to discuss your goals and help you arrange an appointment.  With few exceptions OJW appointments are most often seen at noon on Thursdays.

(DOWNLOAD ADULT ACQUAINTANCE FORM)

(DOWNLOAD THE ADULT MEDICAL HISTORY FORM)

I, _________________________, authorize Dr. Rothstein to wire my jaws closed. I realize that I will need to be on a low calorie liquid diet to achieve my weight loss goal.*  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 web site 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 be means of life style changes, which include a low calorie, balanced diet matched to an appropriate exercise regime for my life style.

I understand that Dr. Rothstein requires a note from my physician indicating that I have no medical conditions that will cause me any problems if I begin a weight loss program based on a liquid diet.

Dr. Rothstein’s work shall be largely limited to placement 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 may cause harm to me.

I am fully aware that other methods of weight loss are available to me including: weight loss medicines such as Alli, Meridia and Xenical, Weight Watcher's and Jenny Craig programs and even surgery.

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 eat a soft diet during those times that 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 forego 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 _________ .

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 Dietician'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 Nippy wire cutter and even a fork. I have been advised to carry at all times the Nippy wire cutter 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 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; I may have to release the wiring immediately because I find that my jaws wired closed feel too strange and uncomfortable.

I understand that the initial wiring fee is non-refundable and that the removal of the wiring and all braces and final cleaning at the last visit will be completed at no charge. I agree to pay a surcharge of $25 for replacing detached brackets after the third one.

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 85  patients. A utility patent application has been submitted to the USPTO.

*_______________________________________ Patient’s signature now and again at time of orthodontic jaw wiring

* orthodontic jaw wiring (Links to sites with information on losing weight and liquid diets, sustaining 
    nutrition and, hazards in dieting)  
*(See a liquid diet that was created by a person who was considering weight control by orthodontic jaw wiring)

** Dr. Rothstein can refer you to local hospitals that provide the services of a registered dietitian. At least 2 visits are needed: The first, for a physical exam and blood samples, at which time you must present an accurate record of your food intake for at least one week. The second, to report to you the results of your blood study, and to provide you with a low calorie liquid diet specifically tailored to your needs and goals. The total cost of those services is about $200.
*** The present fee for OJW is $2685. This fee includes all OJW appointments including removal of the OJW appliance.

What is "Orthodontic Jaw Wiring"?

****What is the purpose of the DPOJW?   THE DENTIST PROVIDERS OF ORTHODONTIC JAW WIRING will be a not-for-profit, tax exempt organization composed largely of dentists and dental specialists (in particular orthodontists), whose panel of advisors will eventually include a lawyer, dentists, orthodontist, psychotherapeutic counselor, and where possible, a bariatric surgeon, a registered dietician and some former OJW patients....The major goal is to acquire funds to carry out research at an appropriate facility (dental school, hospital, weight loss clinic); to investigate whether or not the present protocol for orthodontic jaw wiring (a relatively non-invasive approach to weight loss), is a safe, i.e, without multiple harmful side effects) and effective method to aid overweight and obese persons to lose weight and keep it off lest they become candidates for invasive surgery whose mortality rate 4-5/1000. And if so, to raise awareness of its potential among other health providers such as general physicians...It will support educational activities to help providers understand and appreciate how to provide this service so as to maximize the potential for patients to achieve their weight-loss goals while recognizing and minimizing any potential injuries likely to befall a patient in the short run (3-6 months), or during a more lengthy period of OJW (6-12 months)....It will promote the spread of knowledge of the method to general dentists and orthodontists (by creating continuing educational courses) and to the public at large, by encouraging would-be providers whose numbers at present are limited.