Patient Name:

Parent/Guardian Name:

Patient Address

Street Address:

Address Line 2: 

City: State: Zip Code:  

This letter is to certify patient/patient’s parent/patient’s guardian request the removal of orthodontic appliances and the termination of treatment.

Patient/Patient’s parent/Patient’s guardian has been informed that treatment has not been completed and that Won-Woo Park, DMD, MS recommends the continuation of treatment in order to obtain the best results.

I hereby release Won-Woo Park, DMD, MS, OoLi Orthodontics – AZ PHX, PC & OoLi Orthodontics - AZ Tempe, PC from any responsibility for all consequences caused by early termination of treatment.