Download Installment Plan Agreement

INSTALLMENT PLAN AGREEMENT
_______________________________________ referenced as “Responsible Party”
_______________________________________ referenced as “Patient”
The fees for my orthodontic treatment are calculated as follows:
1) Records Fee - $295
2) Treatment Fee – ONLY THIS PORTION IS ELIGIBLE FOR THE INSTALLMENT PLAN AGREEMENT.
3) Retainer Fee - $495
I Responsible Party agrees to pay the fees for certain orthodontic dental services rendered to Patient by BRACES
BRACES, LLC in the amount of $____________ (the “Treatment Fees”) and, in order to pay the Treatment Fees, I
request an installment plan (“Installment Plan”) so that I may conveniently pay the Treatment Fees over a period of
________months (the “Term”) unless earlier terminated as provided herein. I agree that each monthly installment
payment will be the amount identified below as the “Installment Payment,” with one final payment, at the conclusion of
the Term, of the entire outstanding balance due, if any. I understand that this Installment Plan may be terminated by
Braces Braces, LLC in the event that the orthodontic plan in connection with which this Installment Plan was
established is terminated by me or Braces Braces, LLC for any reason, and that, at such time, the entire outstanding
balance under this Installment Plan shall be immediately due and payable to Braces Braces, LLC. I agree to comply
with the terms and conditions set forth in this Installment Agreement.
Even though this plan is offered with ZERO PERCENT INTEREST, because the terms of the plan require more than
four (4) payments, the law requires the following “Federal Truth in Lending Disclosure”:
ANNUAL
PERCENTAGE
RATE
The cost of your
credit as a yearly
rate.
0.00%
FINANCE CHARGE
The dollar amount
the credit will cost
you.
Amount Financed
The amount of
credit provided to
you or on your
behalf (i.e., sales
price minus any
down payment).
Total Payments
The amount you
will have paid
after all
payments
scheduled.
Total Sales
Price
The total cost
of your
purchase,
including
down
payment.
$0.00
PAYMENT SCHEDULE
Total Number of Payments
Installment Amount
$ __________________
Payment Date
(each month)
Not before the second (2nd)
business day of the month.
Terms and Conditions
Are there fees associated with paying in installments?
1

There is no interest charged and no administrative fee. The Installment Plan is a free service to our
customers. Please note, however, that there are fees (described below) for such things as payment
extensions, returned checks, or costs of collection if you default and fail to pay the amount you owe. Please
note that additional discounts may be offered to customers who pay for services in full, in advance.

How much and how often will I be charged? You will be charged the Installment Amount each month for
the Term (e.g., if the Term is twenty-four (24) months, you will be charged twenty-four (24) times). If any part
of the Fees remain unpaid after the Term, the Term will be deemed extended, and you will be charged one
additional payment during the following month for the entire outstanding balance. This additional payment is
also deemed an “Installment Payment” for the purposes of this Installment Agreement. The first Installment
Payment will be processed the day you sign this agreement. Future Installment Payments are processed on
or after the second (2nd) day of each month after the first month unless the 2nd day falls on a weekend or a
federal holiday, in which case the payments will be processed on the following business day (the “Due Date”).
2

Can I skip a payment? No. We require that all payments are made according to this Installment Agreement.
Please see our Termination policy to see how missed payments can lead to the termination of your orthodontic
care.

What can I do if I expect to have difficulty making an upcoming payment? We have only one Installment
Payment schedule. If you expect that funds will not be available for the ACH/debit/credit card on file, you must
come into our office before the Due Date to change the card number on the Installment Agreement. We may
be able to (but we are not required to) extend your payment date to another date within the same month. No
extensions are available beyond the payment month or more than twice during the Term. There is a fee of
$25.00 associated with any single payment extension granted. This fee must be paid in cash when you
request the extension.

What happens if my credit card does not honor a charge? If your card is declined, we will try to contact
you by telephone or via email using the contact information you have provided. If you are unable to make
prompt arrangements for payment, we may cancel this Installment Agreement and require that you
immediately pay the entire amount of all Fees outstanding. If you do not pay, we may terminate your
orthodontic treatment and refer your account to an attorney to bring legal action in order to collect the
outstanding balance from you. You agree to pay all attorneys’ fees, court costs, and other costs we incur if we
refer your account for the collection of an unpaid balance. Please see our Termination policy to see how
missed payments can lead to the termination of your orthodontic care.

What if I need to change my payment method? If you need to change the credit card on file, you must
come into the office before your next Due Date to update your credit card information and sign a new
authorization.

Can I pay additional amounts towards the Fees so that I can pay off the amount I owe sooner? Yes.
You may make additional payments at any time by contacting our office. The monthly payment amount will
continue staying the same till full balance is paid.

Can I make an Installment Payment by another method instead of you charging my credit card in a
particular month? Changes to the method of payment are accepted in our sole discretion. No partial
payments are accepted. Subject to the approval of one of our office managers, we may allow you to make a
payment in cash, by check, or using another credit or debit card in lieu of an Installment Payment by making
the payment in our office prior to the Due Date.

What if I need to change my personal information? If you need to change your personal information on this
Installment Agreement, such as telephone number, email address, physical address, or credit card billing
address, it is your responsibility to contact our office with the information change. If we are unable to contact
you due to outdated contact information in your Installment Agreement on file, we will be unable to alert you if
we have difficulties with your payment account and this Installment Agreement may be cancelled. Please
remember that a change as simple as your billing address can affect the success of your payments.

Governing law. This Installment Agreement shall be governed by the laws of the State of Georgia. The
parties consent to personal jurisdiction in Henry County, Georgia in connection with any claim, cause of action,
or other dispute in connection with this Installment Agreement and agree to, and hereby waive any objection
to, Henry County, GA as a proper and convenient venue in which to bring any such claims. If any provision of
these Terms of Service is deemed by a court of law to be unenforceable, such term shall be severed and
these Terms of Service shall remain in full force and effect, notwithstanding such severance.