Download Re: Orthodontic Treatment Fee

Re:
Orthodontic Treatment Fee
Treatment – months
I, Dr. ________, will reimburse ______________ if they move mid-contract for the
amount that would be remaining as if they had paid $_____ down and $______ per
month for____ months. Treatment fee totals $_________ ($_______ less 6%
bookkeeping courtesy fee of $_____ for payment in full at beginning of treatment).
_______________________________________________
Parent/Patient Signature
Date
_______________________________________________
Dr. _________
Date
1.
The stated fee includes active orthodontic treatment as has been outlined. This fee
does not include required oral surgical or other dental services performed outside this
office. Additional fees will be assessed for replacement of broken or lost appliances.
2.
It is understood that during the course of orthodontic treatment, consultation with
other medical and dental specialists may be required. With respect to any such
consultation for the benefit of the patient, it is agreed that the identity of the patient,
information relative to the patient’s treatment, and the patient’s orthodontic records may
be disclosed and made available to any other medical and dental specialists that are
consulted. In addition, permission is granted for use of the patient’s orthodontic records
for other consultations and for professional education and publication, so long as
reasonable precautions are taken to guard against the disclosure of the patient’s identity.
3.
It is affirmed that the treatment objectives, plan, alternatives, risk of adverse
effect, probability of success and expected benefits have been explained to the
patient/parent. Having been so informed, the patient/parent consents to treatment.