Sudbury Orthodontics Retention / Debond Letters

Patient Name

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Responsible Party

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Responsible Party's Name

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Completion of Orthodontic Treatment with Ideal ResultsEarly Termination of Orthodontic Treatment With Non-Ideal ResultsRetainer Consent FormOwing Balance Agreement
Owing Balance Amount

Completion of Orthodontic Treatment with Ideal Results

The patient has progressed through a defined period of orthodontic treatment determined at their consultation and :
1. All teeth are ideally aligned to the best of the orthodontist's abilities barring any anatomical limitations which include but are not limited to variability in the size, shape, or position of teeth due to genetics, differential wear, impaction, delayed eruption, extraction, or gingival hypertrophy/atrophy/recession.
2. All spaces/gaps between teeth are closed unless the patient will be completing additional dental work (buildups, implants, or bridges) to idealize the shape/size of teeth or replace any missing teeth. If any spaces are present and cannot be closed due to biological limitations, the patient/parent acknowledges that they are accepting the spaces as is and are financially responsible for any aesthetic/prosthetic work that must be completed by their dentist to fill the gaps/spaces.
3. All gaps/spaces that are for future dental work are ideal and have been confirmed by the patient's general dentist.
4. The overbite, overjet, and relationship of the upper and lower teeth/jaws, including dental and skeletal crossbites have been completed to the best of the orthodontist's abilities barring any limitations due to poor elastic compliance by the patient, inability of the patient to wear elastics due to health or other reasons, frequent breakages of orthodontic appliances by the patient, limitations in the patient's growth potential, limitations in the patient's case itself (patient/guardian declined surgical correction or over correction with other auxiliary appliances.
Other Findings
Early Termination of Orthodontic Treatment With Non-Ideal Results

The patient has progressed through orthodontic treatment without achieving ideal results due to one of more of the following (check each that apply)
Request by the patient/guardian to remove all orthodontic appliances due to personal reasons (documented in patient's chart)Poor oral hygiene resulting in significant damage to the teeth despite repeated discussion for improved hygiene.Poor elastic compliance despite repeated discussion/education on how to wear elastics to improve biteFrequent breakages of orthodontic appliances and auxilariesPatient declined to use/wear recommended orthodontic auxiliaries (Headgear, Facemask, Forsus, TADS etc)
I acknowledge that Dr. D'Aloisio and his associate(s) have documented and discussed the above points with me including any limitations/issues which have prevented the ideal alignment of the teeth and jaws. By signing below I, the patient/guardian of the patient acknowledge that I am satisfied with the results of the orthodontic treatment completed by Dr. D'Aloisio and his associate(s). I do not want to make any further changes to the position or alignment of the teeth or jaws and hereby consent to the removal of all active orthodontic appliances.

In the case where there has been a need for early termination of orthodontic treatment, I consent to the early removal of orthodontic appliances and hereby release Dr. D'Aloisio and his associate(s) from any responsibility for all future consequences caused by early termination of treatment.
Retainer Consent Form
You put a lot of work and effort into your smile. You are now entering an important phase of orthodontic treatment - The Retention Phase

Did you know that teeth can move throughout life? Teeth have memory and often try to move back to their original positions. The job of the retainer is to keep your teeth in good alignment and maintain your amazing new smile.

Sudbury Orthodontics includes a 2-year warranty on bonded lingual wires (also called fixed retainers) from the day they are received. Removable retainers are NOT included in any warranty. Please note that there are exclusions to the bonded retainer warranty that include, but are not limited to the following items below. Anything that is outside the warranty criteria is your financial responsibility.
- Removing/cutting a bonded retainer on your own or from someone other than Sudbury Orthodontics
- Biting into hard foods causes distortion/breakage of wire or breakage of buttons holding the fixed retainer.
- Retainer issues that occur 2 years after they were initially provided to you.
- Failure to come to your retainer check-up appointments
By signing this form, I understand that,
- Wearing retainers is the final phase of the orthodontic treatment and they are required for my teeth to maintain their current alignment.
- To maintain my current alignment, it is ideal to wear removable retainers nightly. You will always need to wear a retainer in order to keep the alignment of your teeth.
- If I elect to not have a bonded retainer, I must wear my removable retainers full time (all day) for the first six months or as instructed by Dr. D'Aloisio- take them out only when you eat or brush your teeth.
- If I choose at any time to stop wearing my removable retainer, there will be a higher risk of my teeth returning to their original positions. Sudbury Orthodontics is not responsible for misalignment due to non-compliant retainer wear.
- Removable retainers are not included in the warranty. Replacing lost/broken removable retainers is my financial responsibility.
By signing below I acknowledge that I understand my responsibilities in wearing and maintaining retainers. I also acknowledge that there is an additional cost to replace lost or broken retainers and any desired re-alignment of teeth.

I Understand
Owing Balance Agreement
I understand that Dr. D'Aloisio has completed my clinical treatment and I will now be entering the retainer phase of my treatment which will continue for the next two years at a 6-month interval. I understand that there is still a balance on my account of ${owingBalance}. This remaining balance will continue to be debited from my bank account/credit card on a monthly basis for the treatment that has been rendered, until fully paid, as per the initial financial contract with Sudbury Orthodontics.
Patient's Signature

By clicking accept and sign, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature.
Patient's Name

First NameMiddle NameLast Name
Responsible Party's Signature

By clicking accept and sign, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office – in just the same way as a pen-and-paper signature.
Responsible Party's Name

First NameMiddle NameLast Name
Date

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Completion of Orthodontic Treatment with Ideal Results

Early Termination of Orthodontic Treatment With Non-Ideal Results

Retainer Consent Form

Owing Balance Agreement