BRACKET AND ORTHODONTIC REMOVAL & POST ORTHODONTIC RETAINER CONSENT FORM

Patient Name:
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Congratulations! Today is the day that your braces are coming off to unveil your beautiful smile! You are now entering an important phase of your treatment – the Retention Phase. Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Teeth have memory and often try to move back to their original positions. Retainers are required to keep your teeth in their new positions. Regular retainer wear is necessary for your lifetime as your body is continually undergoing growth and maturation. Minor irregularities, particularly in the lower front teeth may occur.

In summary, you need your retainers to keep your teeth as straight as possible. But even with good retainer wear, your teeth may move slightly.

I understand that I have the following responsibilities during my retention phase.

Retainer Instructions and Responsibilities:

  • Wear your removable retainers 22 hours a day (including sleeping) for the first year followed by nightly wear for my “lifetime”.
  • Do not wear removable retainers while eating to prevent damage.
  • Keep your removable retainers in the proper case when not wearing them. Avoid putting them in a napkin as this is the most common way a retainer is thrown out by accident.
  • Maintain your scheduled retention appointments as prescribed by my orthodontist if applicable.
  • Bring all removable retainers to my retention appointments.
  • Clean around your bonded retainer / lingual wire
  • Have my General Dentist evaluate the readiness for wisdom tooth extraction if applicable.
  • Call the office immediately if my retainer breaks or is not fitting properly.
  • If a retainer is lost or damaged, call our office immediately to schedule an appointment to prevent teeth movement. There will be a laboratory charge per replacement retainer. If further treatment is required due to unexpected growth or noncompliant retainer wear, additional charges will be applied.

I understand the above information. I have had an opportunity to ask any questions and I have had those questions adequately answered. I consent to the removal of my (child’s) braces/appliances. I also agree to any retention appliances that are placed or prescribed by the Dentist.

Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.

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