Falsafiortho Debond and Retainer Consent Form

Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults

6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com

Debond and Retainer Consent Form

Patient Name:

Congratulations! Today is the day that your braces are coming off to unveil your beautiful smile! 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 and often try to move back to their original positions. Retainers are required to keep your teeth in their new positions. Regular retainer wear is often necessary for a lifetime as your body is continually undergoing growth and maturation. In summary, you need your retainers to keep your teeth as straight as possible, but even with good retainer wear your teeth may move slightly.

Consent for Braces Removal

I am pleased with my/my child’s smile and consent to removal of the braces/appliances

(initials)

Retainer Instructions and Responsibilities

I understand that I have the following responsibilities:

1. Wear my removable retainers 22 hours a day allowing 2 hours to eat and brush for the first 6 months followed by “night-time for lifetime.”
2. Do not wear my removable retainers during eating to prevent damage.
3. Keep my removable retainer in the proper case when not wearing them.
4. Keep my retainers and retainer case away from all pets.
5. Do not expose my retainer to anything hot, this includes hot water; heat will melt or warp your retainer.
6. Brush retainer with toothpaste and cool water after every meal and before going to bed.
7. I will be given your mold of your teeth, please keep in a safe place in case they are needed in the future.
8. Maintain my scheduled retention appointments as prescribed by my orthodontist.
9. Bring removable retainer to my retention appointments.
10. Clean around my lower lingual bonded retainer.
11. Have my General Dentist evaluate the readiness for wisdom tooth extraction if applicable.
12. 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 material. If a retainer is lost or damaged, call our office immediately to schedule an appointment. There will be a laboratory charge per replacement retainer.

I understand the above information. I have had an opportunity to ask any questions, and I have had those questions adequately

answered. I,

, give my consent to have the patient mentioned above braces removed.

Patient’s/Guardian’s Signature:

Relationship to patient

Date:

(Office Manager Mary Godlewski reviewed this information)