Fixed Lingual Consent Form

Patient details

First Name *

Surname *

Date of Birth *

Parent/Caregiver First Name *

Parent/Caregiver Surname *

Fixed Retainers: Please tick ALL boxes to confirm you have understood the relevant information

CLEANING *

Prior to having the retainer fixed, it is important that your teeth are completely clean, improving the strength of the bond and and reducing the risk of breakage.If required, we will ask the patient to visit their dentist for a scale, clean, and polish of this area.Once the retainer is placed, the patient must brush around it carefully and thoroughly with a toothbrush and toothpaste, twice daily.The patient understands that flossing is required once a day to preserve the cleanliness of the area around the retainer.It is important that the patient sees a general dentist for a scale and clean around the fixed retainer every 6 months. There is the risk of gum disease in this area if not regularly cleaned and checked by a general dentist.

DIET *

The patient understands that once retainer is fitted, certain hard foods, raw carrots/hard fruits and vegetables, hard bread crusts and sticky/chewy items should be avoided on the front teeth. Additional care is required if the patient has a retainer bonded to the upper teeth, as these are often used to bite down into food directly.It is also very important to reduce soft drinks, cordial, lollies, and foods with high sugar content, to avoid the risk of decay. If the patient has food or drink with a high sugar content, they should rinse their mouth immediately afterwards with water.

BREAKAGES *

The patient is aware that they must contact the surgery immediately if the retainer becomes loose or feels strange/distorted.The patient is aware hard and crunchy foods such as apples and carrots should be cut smaller and not eaten on the front teeth to avoid breakages.The patient is aware that teeth can move rapidly if the retainer loosens or detaches.The patient will wear their removable retainer over the top to prevent movement until an appointment with the orthodontist can be attended.The patient understands that bonded retainers are intended to remain fixed for several years, however there is no guarantee of this. No-fault repairs where you have not caused damage to the retainer through intention or negligence will be included for the first 12 months. The patient understands that after this, and immediately for any breakages where the patient is at fault or damage has occurred to the retainer requiring complete replacement, a fee will apply.After 2 years, it will be the patient's own responsibility to care for their retainers.

Patient/Caregiver Signatory

First name of patient/parent signing form (must be over 18) *

Surname of patient/parent signing form (must be over 18) *

Email address *

Signature *

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