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Braces Removal Consent

November 12, 2018 by Happy Tooth

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Braces Removal Consent

By completing this braces removal consent form, I understand that I / my child have been evaluated to begin the process of braces removal, Yes, I am satisfied with my (my child’s) new smile.

Once all brackets have been removed I/ my child will be receiving a retainer(s). This is called the
retention phase of the treatment. Typically, the doctor will continue with follow up retainer visits
for about 12 months. My schedule for visits will change during my retention phase. The visits
will be scheduled as follows:

  • 6 weeks after initial retainer insert
  • 3 months after initial retainer insert
  • 6 months after initial retainer insert
  • 12 months after initial retainer insert

After the 12-month retention phase, I will be dismissed as a patient from the practice and will no
longer be required to schedule an orthodontic appointment.

However, I may return for visits as I
desire and I understand that there will be an office visit charge for those appointments.

I understand that if a retainer is lost or broken, I may be charged a fee per retainer to have it
replaced or repaired.

IMPORTANT REMINDER!!!!!!

Compliance during retention is extremely important. If you notice that there is a change in
your smile caused by shifting or movement of teeth, the doctor is always available to reevaluate
you (your child’s) smile. Please understand that if orthodontic treatment and or appliances are required, new treatment fees will apply.

START HERE

 

  • Authorization

    By completing this form, I authoritize that I understand that I / my child have been evaluated to begin the process of braces removal, Yes, I am satisfied with my (my child’s) new smile.

 

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