Contract - JD - Formstack

FINANCIAL AGREEMENT

Patient's First Name:*

Patient's Last Name:*

Responsible Party Name:*

Relationship to patient*

Patient/Guardian Email:

_____________________________________________________________________________________________________________________________________________________

ORTHODONTIC CONTRACT

Contract Start Date:

Initial Exam and Consultation

Diagnostic Records

Initial Banding

First months Fee for Service

Active Treatment

Retainers

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TOTAL CASE FEE:

Less Estimated Insurance

Less Discount

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Remaining Patient Portion

Months:

Monthly Payments:

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THERE IS NO FINANCE OR INTEREST CHARGES IMPOSED UNDER THIS AGREEMENT.

PAYMENTS MUST BE MADE BETWEEN 1ST - 30TH OF THE MONTH AND ARE LATE BY 1ST OF THE MONTH.

$25 CHARGE WILL APPLY TO ALL PAST DUE ACCOUNTS

$25 CHARGE FOR ALL RETURNED CHECKS

$35 CHARGE FOR A MISSED APPOINTMENT

It is the goal of Davidson Orthodontics to provide each of our patients with quality orthodontic treatment that is both affordable and convenient. That’s why we offer our patients an interest free monthly payment plan that substantially reduces the initial expense of placing the appliances (braces) and spreads this cost over the entire course of treatment. Therefore the monthly payment plan does not reflect the fee due for services rendered. The amount due for services rendered is payable if the patient stops treatment. If you would like a copy of the amortization scale, please ask.

In order to maintain this competitive fee structure and so that we may continue to offer these affordable payment terms, it is essential that monthly payments be received by our office by the 30th of each month. Prompt payment is expected and due monthly regardless of scheduled appointments. Accounts which become delinquent will result in the discontinuation of service until the account is made current. Once an account has become delinquent by 60 days the account will be turned over to an outside collection agency.

Should it be necessary to enforce the provisions of this agreement through an attorney or by legal proceedings, the undersigned promises to pay all cost of collection, including a reasonable attorney’s fee and all court costs.

I hereby certify that I have read and received a copy of foregoing disclosure statement.

Agree

Our staff makes a sincere effort to schedule convenient appointments for our patients. However, during the school term, after school appointments will be rotated to equally accommodate each patient. Advance notice of 24 hours is required to cancel an appointment.

Lack of cooperation by the patient (such as poor brushing, not wearing rubber bands, and/or head gear, and continually missing appointments) may result in prolonged treatment.
A cleaning, along with any necessary fillings, must be completed before the braces are placed.
It is your responsibility to keep regular 6 month checkups with the dentist.
Although we accept payments from 3rd party carriers, you are ultimately responsible for the total fee for professional services rendered should benefits be denied to you for any reason.
Responsibility for payment for treatment of minor children, whose parents are divorced, rest with the parent who seeks treatment. Any court ordered responsibility judgment must be determined by the individuals involved, without the inclusion of Davidson Orthodontics.

Davidson Orthodontics hopes that all of our patients understand the importance of this policy. It is our sincere desire to treat our patients in a pleasant and congenial atmosphere. This can best be accomplished when a clear understanding exists regarding financial arrangements.

Thank you for your help in this matter.

I have read and understand this agreement and understand the financial arrangements for fees-due-for-servicesrendered.*

Agree

Responsible Party Signature

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