Debond Comprehensive Form

Congratulations! Today we officially completed your orthodontic treatment.

I have moved your teeth into their most ideal position, equilibrated your bite and fabricated retainers for you to wear. It is important you monitor your teeth because they move throughout life. The best way to do this is through wearing your retainers on a regular basis. The one guarantee I can offer is that if you don’t wear your retainers, your teeth will move.

I acknowledge that I have been offered fixed retainers as a permanent solution. *

I accept. I decline. Furthermore, by declining I acknowledge that if my teeth move there will be a charge for retreating.

I choose *

Only clear retainers (essix) at no additional cost (1st set only). Hawley (metal) retainers at an additional cost of $600.00. Fixed Retainers at an additional cost of $750.00

I agree that my teeth are in ideal position and I am happy with my results from my orthodontic treatment.

Patient Name: *

Signature of Patient/Parent/Guardian: *

Clear

Date: *

Date

Your specific instructions going forward are:

Retainers will need to be worn night time for lifetime.
Wear your retainers as prescribed by Dr. Zeifman.
Due to normal wear and tear of the clear retainers, research shows that they will last about 12 months before they will start to lose rigidity. For this reason we recommend a new retainer every 12 months.

We do understand in some cases the need for new retainers. If you get any dental work done (fillings, crowns) please contact us as soon as the dental work has been completed. You will not get charged for new retainers due to dental work or excessive grinding wear. DOGS LOVE retainers because of the saliva. Keep your retainers in your case and high up on a shelf. Excessive breakage with retainers within the complimentary year will result in the normal essix retainer fee.

Relapse: If you do not wear your retainer your teeth will move again, typically not to a desirable position. So, again, be sure to wear your retainers as instructed to maintain a healthy and beautiful smile