SPACE MAINTAINER/APPLIANCE RELEASE

Space maintainers help “hold space” for permanent teeth. Your child may need one if he or she loses a baby tooth prematurely, before the permanent tooth is ready to erupt. If a primary tooth is lost too early, adult teeth can erupt into the empty space instead of where they should be. When more adult teeth are ready to come into the mouth, there may not be enough room for them because of the lost space. To prevent this from happening, the dentist may recommend a space maintainer to hold open the space left by the missing tooth.

The appliance being made for my child is a temporary appliance used to maintain proper tooth space or to provide better aesthetics or both.

Release

I understand that if my child does not have periodic examinations, problems may occur to the teeth to which the appliance attaches. For example, a band may become loose, which may cause tooth decay or other problems if left unattended. Certain foods (ie: gum, hard or sticky candies, taffy etc) can cause space maintainers to become dislodged. I agree not to hold Dr. Brian Hatch responsible for any problems or additional treatment cost arising from such problems. I acknowledge that it is my responsibility to see to it that Dr. Brian Hatch is notified of any problems or concerns of which I become aware regarding the appliance or instructions for its use and that Dr. Brian Hatch is not responsible for matters arising from any failure to keep him informed.

Payment Agreement I will pay the full amount owed at the initial appointment at which impressions will be taken for the appliance (if impressions are needed). I will pay the balance, less any amount for which there is insurance coverage, when the appliance is delivered. I also agree that after impressions have been taken for the appliance, I will be responsible for the total cost of the appliance even if I choose not to have the appliance placed. I have read and fully understand this Appliance Release and Payment Agreement.

I have received and read the post-op instruction form for Space Maintainers/Appliances.