Great Whites Orthodontics Contract Form PDF Details

Embarking on the journey of orthodontic treatment involves not just a commitment to a healthier smile, but also an understanding of the financial and logistical aspects tied to the process. Great Whites Pediatric Dentistry & Orthodontics, with a team comprising Dawn Sosnick, D.D.S., Regina Hendricks, D.D.S., and Marika Chikvashvili, D.D.S., located in Huntington, NY, provides a comprehensive contract for orthodontic treatment that highlights these critical elements. This contract outlines everything from the total cost of treatment, insurance benefits, and the due dates for initial and monthly fees. Importantly, the contract clarifies that the initial fee is due upon the placement of appliances, with monthly fees expected by the 10th of each month, emphasizing the office policy that there must be no outstanding balance before the removal of appliances. The contract thoughtfully explains what the fees cover, including the active tooth movement phase typically spanning twelve to twenty-four months, plus twelve months of retention and observations. Additionally, it sets the stage for extra costs that may arise, such as for clear braces, replacement of broken appliances, missed appointments without proper notice, and unforeseen growth complications that could extend treatment time. Crucially, it puts the onus on the patient or responsible party to cover treatment fees, with insurance recognized only as partial payment, and any discrepancies or cancellations during treatment potentially leading to additional out-of-pocket expenses. This contract is not just a formal agreement but a roadmap for navigating the orthodontic treatment process with transparency and preparedness.

QuestionAnswer
Form Name Great Whites Orthodontics Contract Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names orthodontic financial agreement, orthodontic contract, ortho contract template, orthodontic treatment plan template

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GREAT WHITES PEDIATRIC DENTISTRY & ORTHODONTICS

DAWN SOSNICK, D.D.S. • REGINA HENDRICKS, D.D.S. • MARIKA CHIKVASHVILI, D.D.S.

755 PARK AVE, SUITE 180 • HUNTINGTON, NY 11743 • 631-261-5100

CONTRACT FOR ORTHODONTIC TREATMENT

THE FOLLOWING IS AN AGREEMENT FOR ORTHODONTIC TREATMENT FOR:

PATIENT ____________________________________________________________DATE________________________________________________

PLEASE READ THIS EXPLANATION CAREFULLY. FEEL FREE TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THE TREATMENT OR FINANCES.

FEES:

THE TOTAL FEE FOR ORTHODONTIC TREATMENT IS $ ______________________

1) INSURANCE BENEFIT

$ ______________________

2) INITIAL FEE

$ ______________________ (DUE WHEN APPLIANCES ARE PLACED.)

3) MONTHLY FEE

$ ______________________ (DUE BY THE 10TH OF EACH MONTH.)

THE INITIAL FEE IS DUE WHEN APPLIANCES ARE PLACED. THE MONTHLY FEE IS DUE BY THE 10TH OF EACH MONTH. OFFICE POLICY REQUIRES THAT AN ACCOUNT HAVE NO OUTSTANDING BALANCE PRIOR TO THE REMOVAL OF APPLIANCES. THIS PAYMENT PLAN HAS BEEN DEVISED FOR YOUR CONVENIENCE. THE FREQUENCY OF VISITS HAS NO BEARING ON THE PAYMENT SCHEDULE.

WHAT THIS COVERS:

THE FEE FOR ORTHODONTIC SERVICES COVERS THE ACTIVE, TOOTH MOVEMENT PHASE OF ORTHODONTIC TREATMENT. THIS USUALLY RUNS FROM TWELVE TO TWENTY-FOUR MONTHS. IN ADDITION, THE FEE COVERS TWELVE MONTHS OF RETENTION AND OBSERVATIONS.

WHAT THIS DOES NOT COVER:

ADDITIONAL FEES WILL BE INCURRED FOR:

•CLEAR BRACES

•EXCESSIVE BROKEN BRACES

•BROKEN APPOINTMENTS WITHOUT 24 HOURS NOTICE

•LOST OR BROKEN APPLIANCES (E.G. HEAD GEAR, RETAINER)

•UNPREDICTABLE GROWTH COMPLICATIONS REQUIRING EXTENDED TREATMENT

ORTHODONTIC INSURANCE:

THE PATIENT OR RESPONSIBLE PARTY IS SOLELY RESPONSIBLE FOR TREATMENT FEES. INSURANCE IS ACCEPTED AS PARTIAL PAYMENT. THIS FORM ESTIMATES YOUR INSURANCE BENEFIT FOR YOUR CONVENIENCE. IF YOUR INSURANCE IS LESS THAN ESTIMATED OR IS CANCELLED ANY TIME DURING TREATMENT YOU WILL BE RESPONSIBLE FOR ANY OUTSTANDING BALANCE ON YOUR ACCOUNT.

RESPONSIBLE PARTY ___________________________________________________________________DATE __________________________

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orthodontic financial contract conclusion process outlined (part 1)

2. The third part is to complete these fields: RESPONSIBLE PARTY DATE.

Stage # 2 in submitting orthodontic financial contract

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