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

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!

This field is for validation purposes and should be left unchanged.