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:*

RiverheadEast Hampton
Responsible Party*

SelfOther
Responsible Party Email*
example@example.com
Responsible Party Phone*
Please enter a valid phone number.
Do you have models?*

YesNo
Please contact the office to coordinate a drop off time.
Select Option*

Upper onlyLower onlyUpper and lower
# 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)*

YesNo
Should be Empty:

Retainer Form