CANDICE ALDRED’S ORTHODONTIC TREATMENTFINANCIAL CONTRACT
Your fee for comprehensive orthodontic treatment is $5997.00
The balance of $5,997.00 is to be paid as follows:
Initial payment of $166.70 is due on October 30, 2020, or prior to the start of treatment.
$166.58 will be due monthly thereafter, beginning December 1, 2020 and continuing for 34 payments, with one final payment of $166.58, until the balance is paid.
Please note if for any reason the full insurance allowance is not paid by the insurance company, the balance remains your responsibility.
Payments are due monthly.
Payments returned non-sufficient funds may incur a late fee.
Financial arrangements are made for your convenience. The amount per month is consistent and does not reflect the number of visits. There may be multiple visits or no appointments at all during a calendar month.
As one of our primary goals is to complete the orthodontic treatment as efficiently as possible, consistent with comfort and a good final result; our fees are based on the complexity of treatment, rather that on the actual number of months in appliances. For this reason we may finish active treatment before your payment schedule is complete. Your payments are still due regardless
of when appliances are removed and has no relationship to number and length of visits per month. Payments continue during vacations and absences.
The orthodontic fee covers all appliances (braces and removable appliances) and adjustments necessary to complete orthodontic treatment. If any part becomes loose or broken, contact the office. Should any of the appliances become broken or lost through patient neglect or carelessness, a separate charge may be made for replacing them.
In the event of non-payment of fees for 2 consecutive months, the patient will be placed on maintenance for 30 days to allow the account to be brought current. If the account is not brought current during this period, all appliances will be removed (subject to emergency care in accordance with dentistry laws) and other arrangements will be made for payment of the account.
In the event of orthodontic services being terminated before the completion of treatment you will be required to immediately pay no less than one-third of the total treatment fee. The remaining balance, if any, will be prorated based on the remaining treatment time.
In the event that the Patient decides to cease treatment for any reason, any unpaid portion of the
total treatment fee shall be immediately due and payable.
Fee adjustments due to premature removal of appliances (i.e. poor cooperation) or continuation of treatment at another office (i.e. transfer out of town) will be evaluated on the amount of time and treatment rendered at our office and not necessarily as to the amount of treatment left to complete.
Treatment duration for orthodontic services is estimated and can vary based on factors such as patient cooperation and unpredictable growth. Poor cooperation, poor oral hygiene, broken appliances and missed appointments will prolong treatment time, negatively affect the quality of the result and put the patient at higher risk of root resorption, cavities, gum disease and other problems. In some cases it may be necessary to terminate treatment prior to completion to prevent further negative side effects
General dental care during orthodontic treatment is entirely the responsibility of the Patient and the Patient’s general dentist. Regular examinations for cavities and teeth cleanings should be made with the Patient’s dentist, and is not the responsibility of the Practice, nor shall the Practice have any liability therefore
A lot of our patients are school age children, it becomes obvious that some of our patients must miss some school some of the time. To help ease the situation, we try to maximize the number of before school and after school appointments. This is accomplished by requiring that certain of our time-consuming appointments, like the placement and removal of the orthodontic appliances, be done only in the late morning or early afternoon. This helps to free the before school and after school hours for more of our short appointments.
We highly encourage you to schedule your next appointment when departing the office after your clinic visit in order to ensure you keep your treatment progress on time. Patients are seen by appointment only. We value your time and have put tremendous effort into our scheduling system. Your scheduled appointment time has been reserved specifically for you.
In the event that an appointment needs to be rescheduled, please try to provide our office with at least 72 hours’ notice.
We ask for your partnership when re-scheduling appointments. The time of day available on short notice may not be as convenient to you as the originally scheduled appointment, however we will always do our best to help find time that works with your schedule
Please call our office prior to your appointment if you have loose or broken appliances or brackets, as your appointment may need to be lengthened or changed to accommodate the repair
After the teeth are in their proper position, we enter the retention phase of treatment. The quoted fee covers lifetime retainers and attendant office visits for adjustments and observation for one year after active appliance treatment.
Our concerted goal is to render the highest quality orthodontic treatment as efficiently as possible, consistent with growth and development and biological principles. In addition we want these services delivered in the most polite, courteous, and friendly atmosphere. We appreciate the opportunity to serve you as we look forward to a successful conclusion.
By signing this you understand and agree that it is our guideline to scan original documents and store the documents in an electronic form. Further, you agree that any agreement bearing a scanned signature, which is printed from the electronic form, has the same force and effect as the original document
I, the undersigned (patient or legally responsible party), authorize treatment to be rendered, and assume financial responsibility as stated above
Financially Responsible: Candice Aldred