Orthodontic Braces Early Removal Consent Form
Use this form to request and document early removal of orthodontic braces and confirm understanding of the treatment implications.
Patient Information
Patient Full Name
*
First 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
Text Message
Guardian/Parent Full Name
First Name
Last Name
Orthodontic Treatment Details
Orthodontic/Dental Clinic Name
*
Treating Orthodontist Name
*
Current Braces Status
*
Upper braces only
Lower braces only
Both upper and lower braces
Other
Date Braces Were Placed
*
-
Month
-
Day
Year
Date
Approximate Time in Treatment
*
Early Removal Request
Requested Early Removal Date
*
-
Month
-
Day
Year
Date
Reason for Early Removal Request
*
Patient Informed About Possible Incomplete Treatment
*
Yes
No
Additional Notes or Supporting Details
Medical/Dental Review
Current concerns or symptoms related to your braces or teeth
Pain
Gum irritation
Broken bracket/wire
Bite concern
Cosmetic concern
None
Other
Recent dental or orthodontic instructions received
Recent x-rays, scans, or evaluation related to the removal decision
*
Yes
No
Not sure
Consent and Acknowledgement
Acknowledgement
*
I agree
I do not agree
Submit
Should be Empty: