Signed Date

Date

OoLi Orthodontics Location

OoLi Orthodontist Name

Patient Name

Patient Address

Patient Email

Patient Phone

Person Responsible for Patient's Orthodontic Treatment

Parent / Guardian Name

Parent / Guardian Email

Parent / Guardian Phone

It has been brought to attention of OoLi Orthodontics that above patient has failed to show up for orthodontic appointments again.  Orthodontic treatment may be terminated if this pattern continues.  Any future missed appointments may result in removal of the braces and immediate dismissal from orthodontic treatment.  We require that patients remember their scheduled appointments to ensure completion of the orthodontic treatment planned for that day.  

Missed or late appointments prolong orthodontic treatment and may potentially contribute to dental health problems.  These problems include loss of tooth enamel, increased risk of cavities and gum disease, and the possibility of injury to the mouth from loose or broken appliances.

Please contact Dr. Park at OoLi Orthodontics as soon as possible to schedule an appointment.  If you are no longer interested in receiving orthodontic treatment at OoLi Orthodontics, kindly provide us with a written request to forward your records to another orthodontist.  If you have decided that you do not wish to continue with orthodontic treatment at all, we recommend that you make an appointment to have the orthodontic appliances removed.  

Sincerely,

W.W. Jonathan Park, DMD, MS