Use this template to craft your own custom version for your practice.
ORTHODONTIC COMPLETION & RETAINER CONSENT FORM
Congratulations on finishing the active phase of your orthodontic treatment!
It’s important for you to understand that completed orthodontic treatment does not guarantee perfectly straight teeth for the rest of your life.
Teeth have a memory and often try to move back to their original positions.
RETAINER INSTRUCTIONS AND RESPONSIBILITIES
Retainers are needed to keep your teeth in their new positions. Regular retainer wear is often necessary for the rest of your life as your body is continually undergoing growth and maturation. Minor irregularities, particularly in the lower front teeth may occur. Because of this, you need your retainers to keep your teeth as straight as possible.
I understand that I have the following responsibilities:
Wear my removable retainers 24 hours a day (including sleeping) for the first two weeks followed by “night-time (10 hours) for life-time” wear.
To avoid wearing my retainers while eating to prevent damage.
Keep my retainers in their case when not wearing them.
Maintain my scheduled retention appointments as prescribed by my Dentist.
Bring all retainers to my retention appointments.
Call the office immediately if my retainer breaks or is not fitting properly to reduce any movement.
I understand that if a retainer is lost or damaged there may be a charge to cover the laboratory cost per replacement retainer.
I understand that if my retainers are not worn and my teeth move, the retainers may not fit.
Orthodontic retreatment may be required and incur an additional fee.
CONSENT FOR ORTHODONTIC COMPLETION
I have requested for the completion of my treatment and I understand that if the treatment is not completed, results may be compromised.
I understand the above information. I have had an opportunity to ask any questions and I have had those questions adequately answered. I am ready to proceed with the completion of my Orthodontic Treatment.
Signed: _______________________ Date: _____________________
Signed Patient/Guardian: _______________________ Date: _____________________