Kylee Plummer

ORTHDONOTICS YOUR ORTHODONTIC APPOINTMENTS Patients Name: In order to ensure quality orthodontics care, it is imperative that both parents and patients understand the manner in which we schedule your appointments. Our goal is to be the best part of your day. We make it a top priority to value both you and your time. That’s why we make every effort to stay on or ahead of schedule. Most parents work and all children attend school. Inconveniencing your work schedule and interrupting your child’s studies as infrequently as possible is very important to our entire office. Since the vast majority of our patients are of school age, it is unavoidable that some school time appointments will be necessary. In order to be fair to all patients we may alternate appointments during school months. We will be glad to work around certain classes that are very important or ones which your child may be having problems. We provide your child with school excuses for scheduled orthodontic appointments and it is important for your child to turn these in to the appropriate school official. We want you to know that our staff will work hard to provide the finest orthodontic care in the most convenient scheduling system possible for you and your child. We also have families and children and understand our scheduling concerns and will do everything we can to ensure that your child’s treatment goes as smoothly as possible.     LONG APPOINTMENTS, BANDING AND BONDING: These are more detailed and technique-sensitive appointments. Therefore, these appointments will be scheduled during quieter morning hours. EMERENGIES :( Pain, Swelling, or bleeding) this usually results from trauma to the face or mouth. These patients will be seen as soon as possible and appropriate care given or referred to another specialist for treatment. REPAIRS: (Loose bands, or brackets, broken arch wires or ties/broken appliances or retainers) these appointments are always scheduled during school hours at specific time since they are long visits. The vast majority of your appointments over the course of treatment will be short appointments. By seeing our longvisit patients during school hours.it leaves more room in our schedule to see more patients after school hours. APPOINTMENTS BROKEN OR NOT CANCELLED WITHIN 48 HOURS: Another appointment will be scheduled but may require waiting 4 to 6 weeks. An appointment during school hours may be arranged sooner. Thank you so very much for understanding! I have read and agree to the scheduling information above. X Parent Signature: ORTHDONOTICS PRACTICE FINANCIAL POLICIES PATIENT: THIS FINANICAL POLICY is in effect for an Orthodontic treatment that will take APPROXIMATELY________months. At the end of this time there will be a Retention Phase that will take approximately_________months. IF TREATMENT IS EXTENDED due to lack of cooperation or traumatic injury, there may be an extra charge per month each month until the braces are removed. IF THERE IS EXCESSIVE BREAKAGE of the braces or loss of removable appliances, retainers, brackets etc., there may be repair or replacement charges to be determined at that time. IF SERVICES PROVIDED BY OTHERS, outside of this Orthodontics practice are not part of the treatment fee. IF ORTHODONTIC INSURANCE covers all or part of the fee, it may be paid directly to the practice or to the policy holder as arranged. Whatever part of the account balance not paid directly to the practice by an insurance company must be paid by the Financially Responsible Person noted below. X FINANCIALLY RESPONSIBLE PERSON 24/10/2017 IF A THIRD PARY not residing with the patient is responsible for the account balance and this third party, defaults on payment, the person named below will take full responsibility for the balance of the account. X PERSON ACCEPTING THIS RESPONSIBILTY PRE-AUTHORIZED DEBIT RELEASE OR PRE-AUTHORIZED CREDIT CARD CHARGE I hereby authorize___________________________, to draft the account identified for an amount equal to $_____________ on the___________day of each month for _______________consecutive months beginning on _________________and a final payment of $____________to equal a total fee of $_________________. Signature: _______________________________________ Date: ___/___/______ Patients Name: ___________________________________ Account#___________ Please provide the name as it appears on the credit/debit card: Name: ___________________________________________ Type of Card: ____________Expiration Date___/_____/_______. Card Number: _________________________________________ You will receive a receipt each month as record of your payment. It is very important to remember that these funds are to be deducted from your account on your specific date. Please remember to record your payments in your check register. You will be responsible for “NSF”, fees and charges in the event of the check is not honoured by your bank. 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.Professional Fee $____________ 2.Less Estimate Insurance * $____________ 3.Estimate Responsible Part Portion $___________ 4.Less initial payment(Due:_____) $____________ 5.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.