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Retainer Consent Form
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Wearing your orthodontic retainer as instructed by Dr. Gregg and Dr. McLaughlin is essential in maintaining the result of your orthodontic treatment! The proper fit of a retainer is an important part of ensuring that your teeth and bite will stay straight, and that the retainer will accomplish its intended purpose without any consequence.
By mailing or delivering your retainer to you without Dr. Gregg or Dr. McLaughlin’s supervision, you are consenting to release Gregg Orthodontics from the following potential side effects/risks of a retainer not seated at the office or under the supervision of one of our doctors. Please check each box to acknowledge you understand the potential side effects/risks.
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A retainer that is too loose or too tight
Undesired tooth movement/shifting
Changes in bite
Tooth wear or damage
Gingival tissue damage or recession of the gums
Pain or discomfort related to retainer wear
Select All
It is always recommended that all patients have their retainer placed and the fit of their retainer checked in the office and under doctor supervision. By signing this, I absolve Dr. Gregg/McLaughlin and Gregg Orthodontics from any responsibility of the above-mentioned consequences. I consent to this any time I request retainers for myself or my child moving forward.
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I agree to the retainer consent.
Patient Full Name
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Parent/Guardian Full Name
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Date
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MM slash DD slash YYYY
Retainer Wear and Care Reminders
Wear your retainers
22/7
Nigh-time
Caring for your retainers
If it’s not in your face, put it in your case!
Keep away from dogs and cats.
Brush your retainers with toothpaste.
Soak in vinegar to remove build-up.
Avoid boiling, microwaving, and the dishwasher.
Name
This field is for validation purposes and should be left unchanged.
