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Early Debond Letter
Patient's First Name:
*
Patient's Last Name:
*
Parent/Guardian Name:
Patient/Guardian Email:
*
Understand, braces and/or appliance is being removed for the following reason(s)
*
Patient/ Parent requests removal of braces and/or appliance(s)
Patient cooperation is poor and discontinuation of treatment is in his/her best interest
Transfer to remote areas necessitates removal of braces and/or appliance(s)
Other:
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I have discussed the decision of discontinuation of treatment with the doctor, all my questions have been answered, and I have been informed that treatment has not been completed.
*
Agree
I hereby release Dr. Jeremy Davidson, Davidson Orthodontics and staff from all liability and consequences caused by discontinuation of treatment.
*
Agree
Patient/Parent's Signature
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Orthodontist's Signature
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