Kylee Plummer

ORTHDONOTICS Patient Name: ___________________________________ ___________Partial Limited Treatment ___________Phase I or Phase II Treatment ___________ Comprehensive Treatment Date:________________ Orthodontic Investment $___________ Estimated Insurance $______________ Payment Option Total $______________ ___________5% same day start savings Payment Options OPTION A: Payment in Full Courtesy Total treatment fee $________less 7.5% courtesy of $________leaving adjustment fee of $_____ 10% courtesy fee $_______ for payment in full today $__________ OPTION B: In Office Payment Plan-Automatic Pre-Authorized An initial down payment of $______is due when treatment begins, with balance paid in monthly payments of $_____ for_____months. No late fees will apply when the account is maintained current. ☐ Visa ☐ MasterCard ☐ Discover ☐ American Express ☐ Check/Savings Account OPTION C: Outside Credit Plan No initial payment. Take up to 36 months to pay, with monthly payments as las as $____. A finance charge is applied. Apply with Care Credit online at CareCredit.com or by telephone at-. Orthodontic treatment is an excellent investment in the overall dental, and psychological wellbeing of both children and adults and financial considerations should not be an obstacle to treatment. We are her to help you and welcome the opportunity to discuss financial arrangements at any time. ORTHDONOTICS ORTHODONTIC FINANCIAL AGREEMENT Date: __________ Responsible Party: _____________________PH: (______) ____________________ Patient: ______________________________Ph. :(_______) _____________________ Treatment Covered by this Agreement: ☐ FULL TREATMENT ☐ PHASE 1 ☐ PHASE 2 1. 2. 3. 4. 5. Professional Fee Less Estimate Insurance * Estimate Responsible Part Portion Less initial payment(Due:_____) Unpaid Balance $____________ $____________ $___________ $____________ $____________ Unpaid balance (#5 above) is payable to Dr_________ in monthly installments of $_______each, and one instalment of remaining balance. The first installment is payable on _________and subsequent installments on same day of each consecutive month until paid in full. A $20.00 late fee will be charged on all accounts which are not received by our office by the end of the month. X X Signature Witness X Date *I understand that this amount is an estimate only and that I am personally responsible for any balance not paid by insurance.