Facing the Future Orthodontics

Retainer Form

Please provide your information below, and our team will be in touch to schedule your visit and finalize payment details.
Patient Name

First NameLast Name
DOB

MonthDayYear
Date
Office for Pick Up:
Responsible Party

Other
Responsible Party Email
example@example.com
Responsible Party Phone
Please enter a valid phone number.Format: (000) 000-0000.
Do you have models?
If yes, please bring your models to your preferred office promptly to ensure timely retainer delivery.
Please contact the office to coordinate a drop off time.
Select Option
# of Essix/# of Pairs
Before we put in a request for new models and retainers to be made, are there any concerns, and when was the last time you wore your retainers?
Please allow 7 business days for retainers to be made. You will receive a call once they’re ready.
Rush Order (within 3 business days, +$25 fee)
Should be Empty:

Retainer Form