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Deband Phase

DOB:*
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Orthodontic Retention Phase Consultation

The orthodontic retention phase is the most important portion of your orthodontic treatment. This is the time that we consider how to protect our investment. You have spent time and money and even more the reason why we got orthodontic treatment in first place.
As part of your contract agreement, I/my child will receive (one) set of upper and lower Hawleys retainers. Most orthodontic patients at completion of treatment have swollen gum tissues. This limits the options of what retainers will fit the best at the time of removing the braces.
Hawleys retainers are the most durable retainers available as well as the most predictable to fit the day you have your braces removed. These retainers will hold your teeth in place and eventually you might wear them only to sleep if the doctor recommends.
You may be interested in a more cosmetic option. If you choose, we recommend that you visit your general dentist for an examination to determine if you have any cavities and to get a dental cleaning. We advise to please wait 6-8 weeks to allow the gum tissues to be normal again before fabricating the new retainers.

We advised all our patients to have an extra set of retainers, as the teeth will tend to shift very rapidly and, in the event, you might require a new one the dental laboratory may take 10-14 days to fabricate them.

Options:

Option #1: Essix retainers: (usually last 1-1 ½ years) 

Fee: $179 per retainer
$350 for (1) set of upper and lower retainers


Option #2: Viveras retainers: (usually last 2-3 years)

Fee: $695 (4) sets of upper and lower retainers


Option #3: Hawleys retainers

Fee: $750 for (1) set of upper and lower retainers


Option #4: Accept only the retainers included in the contract


Please Choose An Option:*

Fee for Re-treatment:

  • Re-treatment within the first 6 months from removing braces:  Minimum fee: $1,800
  • Re-treatment after 6 months from removing brace  Fee: Full treatment fee
I have read the above and understand*
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Orthodontic Treatment Retention Agreement

GO Invisalign Tampa

I understand wearing retainers will help limit the teeth movement from their new position. Your teeth will always tend to move back to a position between where you started and from where you finished. 

 

I understand that teeth have a tendency to move throughout life, so lifetime wear of retainers is strongly recommended.

 

I understand that if retainers are not worn as instructed, the teeth will likely become crooked or space will re-opened again.

 

I understand that retainers should be worn according to these time frames beginning immediately after the removal of orthodontic appliances, unless otherwise instructed by the doctor:

  1. First six months: 22 hours a day (remove it when eating, brushing/flossing, drinking liquids different from water)
  2. Second six months: Every night (after evaluation and if recommended by my orthodontist)
  3. Thereafter: Nighttime wear for life when indicated

 

I understand these parameters are subject to change based on the doctor’s observations and recommendations.

 

I understand that retainers should be cared for as follows:

  • Brush the retainer twice a day with your toothbrush with cold water and liquid antibacterial hand soap
  • Call the orthodontic office immediately if a retainer does not fit properly, breaks, comes unglued, or is lost.
  • Keep retainer out of reach of dogs and pets. ***
  • Keep retainer out of extreme heat or cold.
  • Always bring all retainers to each orthodontic appointment.
  • Don’t boil the retainer or clean with solvents.
  • Don’t adjust retainers yourself.
  • Don’t wrap retainers in napkins during meals – they may get thrown out ***
  • Don’t put retainers in a pocket unless they are inside a retainer case.

 

I understand that there are only two proper places for the retainers: In the patient’s mouth or in the retainer case!


I understand it is my responsibility to take care of the retainers, and to let the orthodontist know if something is not right with the retainers.  I understand that should a retainer break, begin to not fit properly, or become lost, it is the patient's and/or parents responsibility to call the orthodontic office immediately to schedule an appointment to address the situation.  I understand that a replacement retainer will incur a fee.

I understand that the Dr recommended me to have fabricated 2 sets of retainers, to replace the first set in case of getting lost or damaged.

I understand that if the teeth move, the patient may need to have orthodontic treatment again.  In the event braces or other appliances need to be used again within six months of completion of treatment, a minimum fee of $1800 will be charged, in addition to the fee for any new set of retainers. If treatment is needed after six months of completion of treatment, the cost of re-treatment will be a full treatment fee, as well as the fee for any new retainers.

I understand that if the teeth move, the patient may need to have orthodontic treatment again.  In the event braces or other appliances need to be used again within six months of completion of treatment, a minimum fee of $1800 will be charged, in addition to the fee for any new set of retainers. If treatment is needed after six months of completion of treatment, the cost of re-treatment will be a full treatment fee, as well as the fee for any new retainers. 


To replace ANY broken, lost, damaged, or deformed retainer (or any retainer needing replacement for any other reason) there will be a charge according to the type of retainer selected.  These fees apply regardless of the reason for a new retainer or when the original retainer was made. 

 

I understand the urgency of maintaining my appointment once retainers have been ordered. Failure to keep my appointment can result in ill-fitting appliances and additional charges for fabrication of new retainers. 

After completion of the initial 6 months retention phase, an office visit fee of $127 will be charged.

Date*
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Final Deband Instructions

I understand that I have completed the active part of my orthodontic treatment and now will be receiving a set of hawleys retainers, which begins the last part of my orthodontic treatment. I realize that wearing retainers full time is very important because they help to “hold” my teeth in their position. I am satisfied with the present position of my teeth and bite and agree with the doctor that my braces are ready to be removed. I agree to wear my retainers as instructed and maintain regular scheduled retainer check appointments and understand that if I do not do so there could be a relapse of my teeth which would require new retainers or additional ortho treatment (at an additional cost). If I lose or brake my retainers, I know that I should call the office immediately.

Fee for Re-treatment:

  • Re-treatment within the first 6 months from removing braces:  Minimum fee: $1,800
  • Re-treatment after 6 months from removing brace : Full treatment fee

Wear Instructions (Please check that you understand):*
Retention:*
Retention:
  Clear Hawley Wraparound Spring Fixed
Upper
Lower
I have read the above and understand*
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