Treatment finish & retainer consent form

Name: Clear Orthodontics
Telephone: (03) 9363 6300

Fields marked * are required.

Congratulations!!
Today is the day that your treatment is finishing, and fixed attachments will be removed to unveil your beautiful straight smile.

It is important to remind you that teeth have a natural tendency to change position over time. The long-term consistent wear of retainers should reduce this tendency. Therefore, to protect against future movement, known as relapse, we will now work with you throughout the next important phase of your treatment known as The Retention Phase.

This retention phase of treatment needs to be individually tailored for each patient and usually consists of wearing fixed retention appliances in conjunction with removable retainers which are designed to hold the teeth in place once orthodontic treatment has been completed.

Consent for removal of fixed attachments

I am pleased the result that has been achieved and consent to the removal of the braces/appliances/aligners.

I am aware that a retention fee will apply as per my treatment contract outlined at the commencement of treatment.

I am aware that I will need to attend my retainer insert appointment approximately 7 to 9 days after the removal of my braces/appliances/aligners. I am aware that any delay in picking up these retainers may result in relapse which will incur a fee to correct.

Retainer instructions and responsibilities

I understand that I have the following responsibilities:

To wear removable retainers 12 hours overnight only, for life.
Not to wear removable retainers while eating to prevent damage.
To keep removable retainers in the proper case when not wearing them.
To attend all scheduled retention appointments as prescribed by my orthodontist.
To bring my removable retainers to all retention and dental appointments.
To clean as instructed around bonded wire at the back of my teeth and understand any breakages after 12 months from fitting date will incur a fee.
To have regular checkups with a dentist for cleans and if applicable to evaluate the readiness for wisdom teeth extraction.
To call the office immediately if the retainer breaks or is not fitting properly.
I understand that if a removable retainer is lost or damaged there will be a $200 per arch replacement.
I understand that if my retainers are not worn and my teeth move, the retainers may not fit. Orthodontic retreatment may be required and will incur a fee.

I understand the above information. I have had an opportunity to ask questions and I have had those questions adequately answered. I am ready to proceed with having the braces removed.

Patient/Guardians Name*

Date*

Please sign here: