Lingual Braces Consent Form

Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Preferred Contact Method

Previous orthodontic treatment?

Current dental concerns or symptoms

Relevant health notes related to treatment

Were lingual braces explained to you?

Primary reason for choosing lingual braces

Treatment goals or expectations

I understand the risks and care responsibilities and agree to proceed

I commit to attend adjustment appointments and maintain oral hygiene

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to Patient

Final Authorization Signature