Appliance Removal Consent North Carolina

Patient Name*
First Last
Has been evaluated to begin the process of appliances removal.

You are now entering an important phase of your treatment – the Retention Phase. Completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life. Teeth have ‘memory’ of where they once were and a tendency, like all parts of our bodies, to change with age. As such, your teeth might tend to move back to their original positions or shift over time. Retainers are a great way to avoid or minimize post-treatment change and are required to keep your teeth in their new positions. Regular retainer wear is necessary for the rest of your life as your body is continually undergoing growth, maturation and change even as an adult. The retention phase lasts for 12 months and the number of visits will be at the doctor’s discretion. However we recommend the patient continue to wear the retainers a couple of nights a week for life, or as long as you wish to maintain your final orthodontic result!

Retainer Instructions and Responsibilities
I understand that I have the following responsibilities:
- Wear my removable retainers as directed by my orthodontist
- Do not wear my removable retainers during eating to prevent damage.
- Keep my removable retainers in the proper case when not wearing them
- Maintain my scheduled retention appointments as prescribed by my orthodontist.
- Bring all removable retainers to my retention appointments.
- I will continue care with my General Dentist and have him/her evaluate the readiness for wisdom tooth extraction, if applicable.
- If I have my wisdom teeth extracted following orthodontic treatment, it is required that I continue to wear my retainers after my extractions. Failing to do so will result in unwanted tooth movement/relapse and may void my retainer and treatment guarantees
- Call the office immediately if my retainer breaks or is not fitting properly.
Lost or Broken Retainers
Your retainers are made using only the best possible materials. If a retainer is lost or damaged, call our office immediately to schedule an appointment. There may be a laboratory charge for replacement per retainer.
Reason for Removal (Select One Option Below)
Treatment was completed and I am satisfied with the final results! I understand if further treatment is required due to unexpected growth or noncompliant retainer wear, additional charges may be applied.
*By selecting any of the options below, I understand the orthodontic care is incomplete, however I request that treatment be terminated and all orthodontic appliances be removed. Furthermore, I release MyOrthodontist from any and all liability for any adverse consequence that might result from discontinuation of said treatment. I understand I will receive a set of retainers to avoid any further movement of the teeth. I understand that stopping orthodontic care may lead to uncontrolled movement of the teeth and future treatment may be needed.
*At the request of the patient or responsible party,
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*At the request of the doctor
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By signing below, I have read and I understand the above information. I have had an opportunity to ask any questions and I have had those questions adequately answered.
Signature of Patient/Legal Guardian*
Print Name of Patient/Legal Guardian*
First Last
Date*
Date Format: MM slash DD slash YYYY
Preferred Location*

Appliance Removal Consent

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