Orthodontic Treatment Financial Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Account #: _____________________

Financial Agreement Terms

1. Treatment Fees

• The total cost of orthodontic treatment is $________
• Initial payment required: $________
• Monthly payment amount: $________
• Number of monthly payments: ________

2. Payment Options

• Payment in full (5% courtesy discount)
• Initial payment plus monthly installments
• Third-party financing through ________

3. Insurance

• We will assist in filing insurance claims as a courtesy
• Insurance coverage verification is not a guarantee of payment
• Patient/guardian is responsible for all charges not covered by insurance
• Estimated insurance coverage: $________

4. Late Payments and Fees

• Payments are due by the _____ of each month
• Late fee of $_____ applies after 5 days
• Returned check fee: $_____
• Treatment may be suspended for accounts 60+ days past due

5. Early Termination

• Fees will be prorated based on treatment progress
• Administrative fee of $_____ applies
• All outstanding balances must be paid in full

Agreement

I have read and understand the financial policy above. I agree to be responsible for all charges related to treatment.

Signature: _________________________ Date: _____________________________

Practice Representative: ____________ Date: _____________________________