Retainer Replacement & Repair Form

Retainer Replacement & Repair Form
We strive to exceed expectations and are hopeful that your replacement or repair will go smoothly. The best way to ensure that is to read this entire form carefully.

FOR OUR EXISTING PATIENTS:

We typically do not charge an evaluation fee and will schedule you after completing this form.

FOR PATIENTS WE DID NOT PROVIDE TREATMENT FOR:

We charge a $70 evaluation fee that is paid in advance of scheduling and we require that you complete and submit this form. At the evaluation appointment, we may be able to begin the process of replacing or repairing the retainer, however, we cannot guarantee it. A separate appointment may be required after we understand what will be required to replace the retainers.

3D Printed Models: Most retainer replacements are made based on a 3D printed plastic model of your teeth instead of plaster models made from a physical impression mold of your teeth. If you do not already have a 3D printed model based on the CURRENT POSITION of your teeth, we will scan your teeth with our 3D camera system and use our in-office 3D printer to create the model of your teeth. For those who already have a 3D model, in the event your teeth have shifted or dental work has been completed after the 3D model was made, we cannot guarantee the exact fit of a replacement retainer.

We are able to provide retainer replacements and we are able to repair most but not all types of permanent bonded wire retainers. We have numerous retainer options to choose from.

FEES FOR REPLACEMENT & REPAIRS:

All retainer fees are collected prior to beginning the process of repair or replacement. Fees will be confirmed at the evaluation appointment.

IMPORTANT:

Bring ALL existing retainers, 3D printed models, and permanent wire retainers to the evaluation appointment. Even if something is broken, bring it with you please.
Date

MonthDayYear
Date
Patient Status*
Patient Name*

First NameLast Name
DOB

MonthDayYear
Date
Name of Person Completing This Form*

First NameLast Name
Relationship to Patient*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Upper Retainer (Select All Options That Apply)*

I do not have an issue with the upper, does not applyReplace Clear RetainerReplace Hawley Retainer (Acryclic & Wire Framework)Replace/Repair Bonded Wire Permanent RetainerReplace Night Guard/Splint for Tooth GrindingMissing Teeth (Replace/Add a Pontic Tooth on Retainer)My Teeth Have Not Shifted as Far as I Can TellMy Teeth Have ShiftedHave Been Wearing Retainer RecentlyWill Bring a 3D-Printed Model of My TeethDo Not Have a 3D-Printed Model of My TeethWould Like to Discuss Options
Lower Retainer (Select All Options That Apply)*

I do not have an issue with the lower, does not applyReplace Clear RetainerReplace Hawley Retainer (Acryclic & Wire Framework)Replace/Repair Bonded Wire Permanent RetainerReplace Night Guard/Splint for Tooth GrindingMissing Teeth (Replace/Add a Pontic Tooth on Retainer)My Teeth Have Not Shifted as Far as I Can TellMy Teeth Have ShiftedHave Been Wearing Retainer RecentlyWill Bring a 3D-Printed Model of My TeethDo Not Have a 3D-Printed Model of My TeethWould Like to Discuss Options
Additional Comments*
Should be Empty: