Download Cosmetic Dentistry Financial Agreement

Tel: 604 688 6848
Toll Free: 1 866 45 AGORA
Treatment Plan and Financial Options
PROGRAM OVERVIEW
10 DAY PROGRAM
Naturopathic Physical Work-up
Included
A physical examination to diagnose overall health concerns and assess
possibly compromised organs, diet and nutritional deficiencies, and to
provide supplementation and herbs.
Infrared Sauna
Included
This is a gentle process of detoxification which eliminates toxins and
allows stored drug and alcohol byproducts and metabolites to leave the
body.
Auricular Acupuncture
Included
Without using needles, acupuncture points are stimulated to balance the
flow of energy to the body, reduce anxiety and depression and enhance a
calm state of mind.
Neuroreceptor Repair and Regeneration
Included
This unique, highly effective program combines the use of brain nutrients,
vitamins, minerals and amino acids to eliminate the craving, repair and
repattern the brain and balance distressing emotions. It is gentle and
long-lasting.
Agora For Life Program
Included
The synthesis of several modalities which clears repressed trauma and reestablishes emotional, physical, and spiritual equilibrium.
Massage Therapy
Included
Deeply relaxing and restorative, massage further assists in the
detoxification process by helping eliminate stored toxins from the body,
while releasing physical pain and withheld emotional stress, often locked
in muscles and tissues.
Included
Life Aftercare program.
Fee (including HST)
Treatment Plan and Financial Options – 10 Day Program
$14,985
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Tel: 604 688 6848
Toll Free: 1 866 45 AGORA
Treatment Plan and Financial Options
FINANCIAL OPTIONS
Based on the total treatment plan, the following options are available:
Option 1: Lowest Monthly Payment Plan

No Initial payment
$0
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
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Payment ranging from 12-60 months with monthly payments as affordable as:
Low fixed interest rate of 9.9%.
Prepayments can be made at any time without penalty.
5 minute application in office with next day approval. Good credit standing
required or guarantor required.
$317 per month
Option 2: Pay Fee As Treatment Is Provided & Monthly Payment Plan

Initial payment of 50% required before the start of treatment.
$7,493

Remaining 50% to be paid via payment plan. Payment ranging from 12-60 months
with monthly payments as affordable as:
Low fixed interest rate of 9.9%.
Prepayments can be made at any time without penalty.
5 minute application in office with next day approval. Good credit standing
required or guarantor required.
$159 per month
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Option 3: Pay Fee As Treatment is Provided

50% deposit required before start of treatment.
$7,493

Remaining 50% due at treatment start.
$7,493
Option 4: Pay Fee in Full Prior To Treatment Starting
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Payment in full before the start of the treatment of a one- time payment of:
Payment accepted via cash or bank draft.
Total includes HST
$14,985
ACKNOWLEDGEMENT:
1.
This treatment plan and alternative (if applicable) has been described to me. I fully understand
the risks, benefits, and alternatives of the recommended treatment. My questions have been
answered.
2.
I understand that as the treatment progresses, modifications may be necessary and these may
affect the fee. Should this occur, I further understand that the modification of treatment and
the change in fee will be discussed with me at the earliest possible time.
Patient Name (print)
Patient Signature
Treatment Plan and Financial Options – 10 Day Program
Date
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