Premature Orthodontic Debonding Consent Form
Patient Information:
Patient Name: ___________________________________
Date of Birth: ___________________________________
Address: _______________________________________
Phone Number: ___________________________________
Orthodontic Practice Information:
Orthodontist Name: ______________________________
Practice Name: __________________________________
Address: _______________________________________
Phone Number: ___________________________________
Reason for Premature Debonding: Please provide a brief explanation of the reason for
requesting premature debonding of orthodontic appliances:
Potential Risks and Consequences: I understand that choosing to have my orthodontic
appliances (braces) removed before the completion of my treatment may result in the following
potential risks and consequences:
1. Incomplete Treatment: Premature removal may result in incomplete treatment and
suboptimal alignment of teeth.
2. Relapse: Teeth may shift back towards their original positions, leading to relapse.
3. Functional Issues: There may be ongoing functional problems, such as difficulties with
biting, chewing, or speaking.
4. Aesthetic Concerns: Teeth may not appear as straight or well-aligned as they would
have if the treatment had been completed.
5. Additional Costs: Further treatment may be required in the future to correct any issues
arising from premature debonding, which may incur additional costs.
Acknowledgment of Understanding: I, the undersigned, acknowledge that I have been
informed of and understand the potential risks and consequences associated with the premature
removal of my orthodontic appliances. I understand that my orthodontist has advised against
premature debonding and has explained the potential negative outcomes. Despite this advice, I
choose to proceed with the premature debonding of my orthodontic appliances.
Release of Liability: I hereby release and hold harmless my orthodontist, the orthodontic
practice, and all associated staff from any liability, claims, or damages that may arise as a result
of my decision to have my orthodontic appliances removed prematurely.
Signature:
Patient Signature: ___________________________________
Date: ___________________________________
If the patient is a minor:
Parent/Guardian Name: ______________________________
Parent/Guardian Signature: ___________________________
Date: ___________________________________
Orthodontist Confirmation: I, the undersigned orthodontist, have explained the potential risks
and consequences of premature debonding to the patient (and parent/guardian, if applicable), and
I have provided my professional advice regarding the completion of treatment.
Orthodontist Signature: ______________________________
Date: ___________________________________
