Orthodontic Appliance Removal Consent Form

I, the undersigned, hereby give my consent for the removal of orthodontic appliances, including braces, wires, and any associated dental devices, by the orthodontist named above. I understand that the purpose of this procedure is to complete my orthodontic treatment and achieve the desired results.

I have been informed and understand the following:

  1. Procedure Explanation: The orthodontic appliance removal procedure involves the careful removal of braces, wires, and any other dental devices used in the course of my orthodontic treatment.
  2. Potential Discomfort: I am aware that during the removal process, there may be some pressure, pulling, or discomfort, but it should be brief and tolerable.
  3. Post-Removal Care: I understand that there may be some adjustments needed after the removal of the orthodontic appliances, such as retainers or additional dental work, to ensure the stability of my teeth alignment.
  4. Responsibility for Follow-Up: I acknowledge that it is my responsibility to attend all recommended follow-up appointments with the orthodontist and adhere to any post-treatment care instructions provided. The dentist is not responsible for any relapse due to uncontrollable factors such as: Periodontitis, unreligious wear of retainers, unstable bone due to different factors like underlying diseases, and even single to multiple missing tooth/ teeth can cause unnecessary tooth movement.
  5. Risks and Benefits: I have been informed of the potential risks and benefits associated with the removal of orthodontic appliances. The potential benefits include improved dental alignment and an enhanced smile, while potential risks may include minor damage to the teeth or dental restorations during the removal process.
  6. Alternative Treatments: I am aware that alternative treatments and options may be available, and I have discussed these with my orthodontist.
  7. Questions and Concerns: I have had the opportunity to ask questions and have received satisfactory answers regarding the orthodontic appliance removal procedure.

I understand that this consent is given voluntarily, and I have not been subjected to any undue pressure or coercion.

    Patient Information:

    Orthodontist Information:

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    Please keep a copy of this consent form for your records.