Orthodontic Appliance Removal Waiver
Use this form to request orthodontic appliance removal and acknowledge the related risks, follow-up needs, and aftercare instructions.
Patient Information
Patient Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
*
Phone
Email
Orthodontic Treatment Details
Orthodontist or Practice Name
*
Current Treatment Status
*
Please Select
Active treatment
Completed treatment
Paused treatment
Follow-up visit
Other
Appliance to Be Removed
*
Braces
Clear aligner attachments
Retainers
Other
Approximate Treatment Start Date
-
Month
-
Day
Year
Date
Removal Request and Scheduling
Reason for Removal Request
*
Treatment completed
Recommended by orthodontist
Moving away
Personal preference
Other
Preferred Removal Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Special Instructions for the Removal Visit
Waiver and Acknowledgment
Patient Signature
*
Submit
Submit
Should be Empty: