PATIENT INFORMATION

First Name

Last Name

E Mail

Phone Number

Address

City

State

Zip Code

CURRENT STATUS

Current Weight

Goal Weight

Activity Level (check one)

Inactive

Midly Active

Moderately Active

Very Active

Number of months you will dedicate passionatley (check one)

Two Months

Three Months

Four Months

Five Months

Six Months

MEDICAL HISTORY

Dentist Name:

Address

City

State

Zip Code

Phone Number

Doctors Name

Address

City

State

Zip Code

Phone Number

Do you have any health issues? If yes, please describe.

List of current medications

Date

Signature

I give Dr. Adedolapo Ayediran my permission to call my physician by placing my initials here

PATIENT INFORMATION

* Instruction: Review and answer all questions, Sign and Date then press submit form button at the end.

* OJW* preferred appointment date:

** Alternative OJW* appointment date:

or “Date undecided”

I, (add name below)

authorize Dr. Adedolapo Ayediran 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. Adedolapo Ayediran'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. Adedolapo Ayediran 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. Adedolapo Ayediran will rebond up to five detached brackets at no charge if you can return to the office. Otherwise, she 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. Adedolapo Ayediran 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. Adedolapo Ayediran'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. Adedolapo Ayediran 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. Adedolapo Ayediran'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 she 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. Adedolapo Ayediran re-examine me to ascertain that my teeth, gums and jaw joints (TMJ) are in healthy condition. Above all, I understand that she will not rewire me if I cannot pass the three-finger mouth opening test without difficulty or discomfort. Finally, that Dr. Adedolapo Ayediran 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 as Overeaters 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. Adedolapo Ayediran 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:

Initial Here

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. Adedolapo Ayediran 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. Adedolapo Ayediran this log at each office appointment. I realize that I may not reach my weight loss goal, but I do not hold Dr. Adedolapo Ayediran responsible since she 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. Adedolapo Ayediran 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. Adedolapo Ayediran 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. Adedolapo Ayediran gave me. Dr. Adedolapo Ayediran 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. Adedolapo Ayediran has/will give(n) me her home phone with special instructions to call her 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. Adedolapo Ayediran 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. Adedolapo Ayediran 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* thatDr. Adedolapo Ayediran 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. Adedolapo Ayediran 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. Adedolapo Ayediran, if she chooses, to show the chart entries of my case on her website in the “orthodontic jaw wiring for weight loss section.” I realize she will respect my right to anonymity. And, I authorize Dr. Adedolapo Ayediran to share my records with other dental, medical and related healthcare professionals concerned with helping the overweight control their problem as part her 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. Adedolapo Ayediran 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. Adedolapo Ayediran is going to provide me with. My signature acknowledges my consent for Dr. Adedolapo Ayediran 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. Adedolapo Ayediran 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. Adedolapo Ayediran will be using wire almost half as thin as the wire now in use with standard brackets. She calls this technique OJW*: Ultralite.

I am aware that some variations of the size, form and position of the teeth she 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. Adedolapo Ayediran has informed me that the 3D bracket is in the Beta (Testing Phase) and she 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. Her initial assessment is they add no more risk to OJW* than with using metal. Dr. Adedolapo Ayediran 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, she will do her 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. Adedolapo Ayediran?

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?

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

Upper Right

Upper Left

Lower Right

Lower Left

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

What research have you done to familiarize yourself with OJW*?

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

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

I will let you know the fee (generally not more than $2,985) after reviewing the data in your completed forms.
Effective July 19, 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 fully refundable upon 48 hours of notice. Without such notice, if you miss your OJW* fitting appointment, it will be applied to the fee due when you reschedule. The balance is due at the fitting appointment.