Orthodontic Treatment Contract Template

The total sum of.

Orthodontic treatment contract template. Even though great care and diligence will be used in treatment no promises or guarantees for desired results can be made nor expected. Orthodontic treatment contract patients name. Approved leaves for orthodontic treatment are subject to staff authorization and must be accomplished within the job corps approved leave limitations. Future have any interest in the care and treatment of myself my child that i have on my own volition and as my voluntary act requested removal of my orthodontic appliances by dr.

Total treatment fee 3. This amount will be paid in accordance with the following payment schedule. Arrangements are made regarding the applicants treatment. Professional fee metal 2.

This agreement covers a 1st stage orthodontic treatment phase only. If insurance is applicable toward orthodontic treatment the total treatment fee will be filed with the insurance company at the time the appliance placement fee is paid. Orthodontic treatment your doctor has recommended the invisalign system for your orthodontic treatment. Patient payment agreement form.

By downloading these available dental forms including this patient payment form communicating clearly with your dental patients will become easier. Orthodontic treatment contract i understand that treatment of dental conditions pertaining to orthodontic treatment straightening or repositioning of teeth includes certain risks and potential unsuccessful result. The appliances are durable and should last through the entire treatment period. This form explains what comprehensive orthodontics treatment is what you can expect from orthodontic treatment and what responsibilities you must assume as a patient or parent in order to make treatment a success.

Dental staff will also have proof of communication with patients. An initial down payment of. All appliances needed to complete the treatment will be provided by dr. Although orthodontic treatment can lead to a healthier and more attractive smile you should also be aware that any orthodontic treatment including orthodontic treatment with invisalign aligners has limitations and potential.

I further acknowledge that said doctor has advised me against removal of said appliances. The insurance filing will reflect the amount of the placement fee paid and contracted monthly maintenance fees. In consideration for such orthodontic services to be rendered the undersigned party or parties promises to pay dr. An additional fee may be charged for excess breakage of the braces.

Estimated time of treatment.