Financial Agreement
Date:
We are excited to create an ideal smile. Below are the details of the financial agreement you have chosen. By signing this contract you are agreeing to comply with the terms outlined below. You will receive a signed copy of this contract and we will maintain the original on file.
Estimated Fees
Patient:
%PatientNameFirst% %PatientNameMiddle% %PatientNameLast%
Responsible Party:
Sub Total:
Est. Length of Treatment:
Months
Estimated Insurance:
Full Case Fee:
Insurance Fee Adjustment:
Coupon/Discount:
Est. Patient Balance Due:
Sub Total:
Contract Terms
INTEREST FREE
Est. Patient Balance Due:
Down Payment:
Contract Length:
Months
Monthly Investment:
Final Payment:
I understand that payments for this option do not include interest or service charges and that this payment plan is to be paid in full either before or by the end of treatment. Should this contract become delinquent, orthodontic treatment may be suspended until the remaining balance is paid in full. I agree that this is a financial contract that is independent of orthodontic treatment.