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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.