Orthodontics Contract Form PDF Details

Navigating the legal maze of obtaining contractual agreements for orthodontic services can be complex and overwhelming, especially if you're unfamiliar with the industry standards. Making sure all parties are on board with any commitments posed is essential in protecting both practitioner and patient. This blog post will explain exactly what an Orthodontics Contract Form should include, what to watch out for when signing contracts, as well as how to ensure everyone involved understands the expectations of their obligations going forward. With a clear outline of what's at stake and proper documentation in hand, you'll ensure that both sides meet their agreement requirements each step of the way!

QuestionAnswer
Form NameOrthodontics Contract Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesorthodontic financial agreement, orthodontic contract, ortho contract template, orthodontic treatment plan template

Form Preview Example

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 __________________________

How to Edit Orthodontics Contract Form Online for Free

Any time you need to fill out ortho contract, there's no need to download any kind of programs - just use our online PDF editor. The editor is consistently maintained by us, getting powerful features and becoming even more convenient. For anyone who is seeking to get started, here's what it will take:

Step 1: Just click the "Get Form Button" at the top of this page to get into our pdf editing tool. There you will find all that is required to work with your file.

Step 2: When you launch the online editor, you will find the document ready to be filled out. Aside from filling out various blanks, you may also perform many other actions with the form, that is writing your own textual content, modifying the initial textual content, adding images, signing the form, and more.

With regards to the blanks of this specific form, here's what you should do:

1. Fill out your ortho contract with a number of essential blank fields. Collect all the required information and ensure there is nothing forgotten!

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

Many people frequently make errors when completing RESPONSIBLE PARTY DATE in this section. Don't forget to go over everything you type in here.

Step 3: Right after rereading the filled out blanks, press "Done" and you are all set! Create a free trial plan with us and get immediate access to ortho contract - which you may then begin using as you wish from your FormsPal account. FormsPal provides secure document editor with no data record-keeping or any kind of sharing. Feel safe knowing that your information is in good hands with us!