I will not have any breakage during my orthodontic treatment anymore. Our office policies and the guidelines of your insurance consider these acts noncompliance on your part.

Please sign below agreeing that you will be compliant with keeping all appointments scheduled in our office and not having any breakage. The first time a scheduled appointment is not kept or there is any breakage you will be dismissed from our orthodontic care.

Dr. Rebecca Falsafi
Your Orthodontist