Rebecca Falsafi DDS, MS
3D Orthodontics and Orthopedics for Children and Adults
6161 Transit Rd., Suite 10
East Amherst, NY 14051
www.falsafiortho.com
IMPRESSION CONSENT
Dear Responsible Party/Patient:
We are pleased to announce that you will soon be ending your active phase of orthodontic treatment and going into the retention phase of treatment. This phase begins with impressions taken of your teeth; from these impressions, your retention appliances will be made. Following this appointment, your braces will be removed and you will get your retention appliances. Please check off the retention appliances that you will receive:
Removable Hawley Acrylic Retainers (upper and lower)
Removable Essix Retainers
Bonded (Fixed) Lingual Retainers
Positioner Appliance
Please inform us at this time if you have any restorations (fillings, etc.) on your front teeth or crowns on back teeth. During the debond procedure there is a possibility that your restorations could be damaged.
This information has been explained to me and any questions I have regarding the active phase and retention phase of treatment have been answered. The type of retention appliance that will be used has also been explained to me.
I am giving consent to remove the braces and I am satisfied with the orthodontic results:
Patient/Parent
Date:
Patient Name:
Date:
Patient/Parent Signature
