Consent for Appliance Removal and Retention Guidelines

Consent for Appliance Removal and Retention Guidelines
Patient Name*

First NameLast Name
Congratulations! It is almost time to say hello to an awesome new smile and start the next phase treatment — the Retention Phase.

Completed orthodontic treatment does not guarantee straight teeth for the rest of your life. Retainers are required to keep your teeth in their new positions since your body is continually undergoing growth and maturation. A certain amount of settling of your teeth is normal. However, unwanted tooth movement will be minimized, if not prevented, by wearing your retainer as instructed.
Things to know:
- 1 set of upper and lower clear retainers is included in Treatment Fee
- They are guaranteed from breakage for 3 months
- Retainer checks at are scheduled at 3 months and 12 months after orthodontic treatment is complete
- Office visits after this 1 year period will be charged on a Fee-for-Service Basis
- If a retainer is lost or damaged, please call our office immediately to schedule an appointment. There will be a charge for fabricating a replacement retainer which has been lost.

Retainers are for LIFE!
To maintain the beautiful smile you worked so hard for throughout your treatment, you’ll have to commit to a long-term retention plan.

We know that LIFE HAPPENS. We have seen people LOSE or THROW AWAY their retainers accidentally. They may become WORN or CRACKED over time or new DENTAL WORK can preven them from fittting properly. We have even heard of PETS chewing on retainers! To provide peace of mind and help you protect your investment, we offer our patients 2 options for extra retainers at a reduced cost.

6 Year Retainer Program
- Up to 4 replacement retainers every 12 months
- Program cost is $675 or 3 payment of $225
- $20 copayment per retainer
Extra Set of Retainers
- Additional set of retainers provided at the end of treatment
- $300 due at debond
What would you like to do? Remember, the first set of clear retainers are included in your treatment.*

6 Year Retainer Program for $675.1 Extra Set of Retainers for $300.6 Year Retainer Program already purchased.Decline Retainer Plan and Extra Retainers. I understand that replacement fees for clear retainers are $200-300 each, and may require additional appointments to be remade.
What would you like to do?
Remember, the first set of clear retainers are included in your treatment.
6 Year Retainer Program for $675.
1 Extra Set of Retainers for $300. Decline Retainer Plan and Extra Retainers. I understand that replacement fees for clear retainers are $200-300 each, and may require additional appointments to be remade.*
How would you like to pay for your 6 Year Retainer Program?*

Pay in Full at Debond$225 due at Debond and 2 monthly payments of $225 set up on Auto Payment

Consent for Appliance Removal
I understand the above information. I have had the opportunity to ask any questions and I have had those questions adequately answered. I am ready to proceed with the removal of braces/appliances for {patientName}.
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Consent for Appliance Removal and Retention Guidelines

Retainers are for LIFE!

Consent for Appliance Removal