I hereby certify, on behalf of my child, and all those who may now or in the future have any interest in the care and treatment of my child, that I have, on my own volition and as my voluntary act, requested removal of my child’s orthodontic appliances by Dr. Shaw.
I further acknowledge that Dr. Shaw has advised me against removal of said appliances at this time, and has informed me that there are significant risks in doing so, including, but not limited to, shifting of teeth, impairment of treatment results, relapse, and decline in my child’s dental and orthodontic health, as well as the consequences resulting there from, and specifically including the following risks: relapse of the teeth, deterioration of the bite, worn or chipped edges of the teeth resulting from future tooth wear as it relates to a poor bite, pain of the joints of muscles of the head and neck, inability to clean around the teeth, gum disease, poor esthetics, effects on self-esteem, and other discussed risks.
In consideration of, among other things, said Doctor’s agreement to remove my child’s appliances at my request and such removal, the sufficiency of which is hereby acknowledged, I do hereby, on behalf of my child, and all those who may now or in the future have any interest in the care and treatment of my child, now and forever release and discharge said Doctor, his/her agents, employees, professional corporation, insurers and assigns from any loss, costs, damages or expenses arising out of the removal of my child’s appliances as aforesaid. I understand that this is a full waiver and release of any and all claims my child or anyone claiming through or on behalf of my child may now have or may acquire in the future arising out of the removal of my child’s appliances as aforesaid by Dr. Shaw, his agents or employees. I further understand that, by executing this Release and Waiver and said Doctor’s agreement to remove my child’s appliances at my request and such removal, my child and anyone claiming through or on behalf of my child will be forever foreclosed from any claim for damages arising out of or related to the removal of said appliances as aforesaid.
This Release and Waiver is the entire agreement between Dr. Shaw and the undersigned party. The undersigned, in executing this Release and Waiver, acknowledges that the consideration recited herein is the consideration for the full and final release and waiver contained herein, and that no other understandings or agreements, representations or promises, verbal or otherwise, have been relied upon by the undersigned in executing this Release and Waiver.
Replacement Retainer Fees
$250 per retainer (upper or lower)
$35 per pontic tooth
Acrylic Wire (Hawley) Retainer
$280 per acrylic wire (Hawley) retainer
$200 replacement of the whole bonded retainer
$35 per pad per tooth (to re-bond a current bonded retainer)
*** An office visit fee of $50 will be charged after the first year of retention
*** Replacement retainer fees are the responsibility of the patient
*** It will be the patient’s responsibility to replace ill-fitting retainers that were not picked-up at the office as advised (the next day unless stated otherwise)
I understand the above information. I have had the opportunity to ask any questions & I have had those questions adequately answered. I am ready to proceed with the removal of my braces.