Congrats! It is time to start planning for retainers!

Please complete the form below so we may plan accordingly:

 

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"*" indicates required fields

This field is for validation purposes and should be left unchanged.
1. Patient Name*

2. Our office provides one Clear, removable retainer per treated arch. You may want to consider a back-up set in case of an emergency to reduce the risk of relapse.

We are able to offer these back-ups at $50 per arch ONLY IF they are included in the original retainer order.

Please select all back-up options you want to add to the original order:*

3. Our retainer provider offers a Take-Home Whitening Kit that can be used with your retainer(s). This is a convenient 14-night regimen with 4 gel syringes to brighten the teeth.

Would you like to add a Whitening Kit for $50?*

Please note this is the cheapest we will ever be able to offer these items because they will be fabricated/shipped with the original order!

Payment for selected items will be due before or upon arrival to the next visit.

Make sure to hit "SUBMIT" below!