retainer-agreement.doc - RETAINER AGREEMENT(PLEASE SIGN AND RETURN PRIOR TO REMOVAL OF BRACES Patient Date Congratulations Within a short period of time

retainer-agreement.doc - RETAINER AGREEMENT(PLEASE SIGN AND...

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RETAINER AGREEMENT (PLEASE SIGN AND RETURN PRIOR TO REMOVAL OF BRACES) Patient: _______________________________________________________________ Date: _________________ Congratulations! Within a short period of time, braces will be removed and retention phase of treatment will begin. We look forward to providing you with retention follow-up services. Please read this agreement carefully and advise us if you have questions. 1. Prior to the removal of braces, we welcome any concerns you have about your smile. Any adjustment that is easier to accomplish with the braces on. 2. Arrangements on any balance due on active treatment must be taken care of prior to the removal of braces. There is a balance of _________. 3. The fee for the retainer is _______. After ____ months, office visit charges will apply. If relapse occurs because of lack of retainer wear, adjustments will be required and additional fees charged. 4. Because the retainers are made of plastic, they must be given the utmost care. Avoid contact with hot liquids and leaving them in any hot areas (near heater, exposed to sun, etc.). They should also be brushed thoroughly at least once a day.

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