Dr. Name
Office address
City, State ZIP
(or preferrably print on letterhead)

DATE

Jane Doe
Address
City, State Zip

Dear ___,

Our office strives to provide high-quality orthodontic treatment to patients, so they will end up with a beautiful smile. To do this, however, requires commitment by both the dentist and the patient.

Unfortunately, we feel that you are not demonstrating the commitment necessary to attain satisfactory results. Specifically, we have noted:
- Wires, brackets, and elastics have been purposely removed by you;
- You have excessive bracket breakage;
- When you have a problem, you fail to make an appointment in a timely manner;
- You fail to come in for necessary periodic adjustments for months at a time;
- You show up late to scheduled appointments, compromising our ability to get your work done;
- You miss many scheduled appointments, delaying your entire treatment;
- You fail to respond to our attempts to reach you to schedule necessary appointments.

Your lack of commitment and cooperation in your own treatment can have many life-long consequences, including:
- White decalcifications on the front of the teeth;
- Crooked teeth;
- Upper and lower teeth not biting together correctly;
- Unexpected movement of teeth;
- Cavities;
- Abscessed teeth that would require root canal treatment or extraction;
- Gum disease;
- Infection;
- Loss of bone holding the teeth in;
- Loss of teeth.

We have tried very hard to accommodate you. In order for us to get satisfactory results at this point, we expect you to:
- Show up within __ minutes of your scheduled appointment time;
- Call us with __ hours notice if you cannot make an appointment;
- Go no more than 45 days between appointments for any reason;
- Call for an appointment within __ days if you find any new problems;
- Not remove any wires, brackets, or elastics on your own without our permission;
- Follow the teeth brushing and cleaning instructions that have been provided to you;
- Follow the eating guidelines that have been provided to you.

Our records show that your orthodontic treatment is not finished. With your full cooperation, we estimate that it would take from ___ to ___ months to finish treatment. Without your full cooperation, it is impossible to estimate how long it would take, and might never reach completion.

If you choose not to finish treatment, or do not think you will be able to do your part required for completion of treatment, you should make an appointment with us to have your brackets and wires removed, as they can do more harm than good if ignored.

If you do not demonstrate the necessary cooperation needed to complete treatment satisfactorily, then we will end your orthodontic treatment, and terminate your patient status at this office.

Please contact us within 30 days to continue treatment. If you are not seen for a scheduled appointment within the next 30 days, we will assume that you no longer want to be treated by us, are no longer our patient, and will seek all future dental treatment at another dental office.

Sincerely,

Dr. ____