• Orthodontic Appliance Checklist Form

    Please complete this checklist to ensure proper use and maintenance of your orthodontic appliance.
  • Date of checklist completion*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Did you wear your appliance as instructed today?*
  • Did you clean your appliance as recommended?*
  • Which cleaning methods did you use?
  • Did you experience any discomfort or issues?*
  • Have you followed all orthodontist instructions?*
  • Are you running low on any supplies (elastics, cleaning solution, wax, etc.)?
  • Should be Empty:
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