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I. The stated fee includes active orthodontic treatment as has been
outlined. This fee includes one set of retainers and supervision of retention
for two years after Phase II/Comprehensive treatment. This fee includes
one set of retainers and supervision to full eruption after Phase I treatment.
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.
Practice of:
II. Fee payments in the amount stated are due on the first of each month.
Monthly statements may be sent on past due accounts. A late payment fee
of 1% per month may be charged on past due balances.
III. Payment of all fees under this Contract is the primary responsibility of
the patient/parent. All such payments shall be made directly by the
patient/parent to our office. We will be happy to assist in preparing
necessary forms to help collect benefits from insurance companies, but it
shall be the ultimate and primary responsibility of the patient/parent to
submit the necessary forms and secure any benefits that may be due.
Date:
Patient:
Address:
FEDERAL TRUTH IN LENDING DISCLOSURE STATEMENT
FOR ORTHODONTIC SERVICES RENDERED
1. Professional Fee, Phase I/Phase II/Comprehensive – mo. $
2. Initial Fee
$
3. Unpaid Balance
$
Unpaid Balance of $
to be paid in monthly payments
IV. 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 who 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.
V. It is affirmed that the malocclusion concerns, basic treatment objectives,
treatment plan, alternatives in addition to no treatment, risk of adverse
effects, probability of success, and expected limitations to treatment have
been explained to the patient/parent. Having been so informed, the
patient/parent consents to the treatment.
VI. We agree to the payment schedule as stated and to perform all of our
obligations under this agreement.
of $ beginning
Patient/Parent_____________________________________Date_______
Orthodontist______________________________________Date________