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Orthodotic Contract

The document outlines the terms of an orthodontic treatment contract. It details the type of treatment, downpayment amount, total treatment fee, and monthly fee. It specifies what is included in the package such as cleanings and extractions, and what is not covered like x-rays and retainers. The contract specifies that the patient must attend monthly adjustments and outlines additional fees for missed appointments or lost/removed brackets. It concludes by requiring the patient's signature to confirm understanding of the agreement.

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Cristine Edam Saret
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198 views2 pages

Orthodotic Contract

The document outlines the terms of an orthodontic treatment contract. It details the type of treatment, downpayment amount, total treatment fee, and monthly fee. It specifies what is included in the package such as cleanings and extractions, and what is not covered like x-rays and retainers. The contract specifies that the patient must attend monthly adjustments and outlines additional fees for missed appointments or lost/removed brackets. It concludes by requiring the patient's signature to confirm understanding of the agreement.

Uploaded by

Cristine Edam Saret
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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ORTHODONTIC TREATMENT CONTRACT

Patient Full Name: ____________________________________________________________________Age: _____________________________

Date of Installation: ____________________________________________________________________________________________________

Attending Dentist: _____________________________________________________________ License Number: __________________________

Welcome to Vandam Cares Family! Congratulations in taking the step towards a healthy and beautiful smile . Below are the
following components of your orthodontic treatment and payment details. Please read carefully and feel free to ask questions you may have.

TYPE OF ORTHO TREATMENT: METAL / CERAMIC / SELF-LIGATING


DOWNPAYMENT:
TOTAL TREATMENT FEE:
MONTHLY FEE (PPE fee not included):

PACKAGE INCLUSION:
The fee of orthodontic treatment covers the active tooth movement phase of orthodontic treatment. This usually runs from 24 months or more
varying on the case and the patient compliance of the treatment.

Patient will also receive the following treatment included on the package:
• 1 Oral prophylaxis (cleaning)
• 1 Tooth Extraction (Simple case only)
• 1 Tooth Restoration (Mild case only)
Severe cases of the above-mentioned treatments are not considered as FREE provided with FULL and COMPLETE explanation from the
attending dentist.

WHAT THIS DOES NOT COVER:


Additional fees will be incurred for:
• Panoramic X-ray
• Removed and lost brackets
• Orthodontic kit
• Retainer
• Unpredictable growth complications requiring extended treatment (wisdom tooth surgery, etc.)
PATIENT COMPLIANCE:
• Orthodontic adjustment must be done every 3-4 weeks.
• Should the patient skip monthly adjustments, an ADDITIONAL FEE OF P500 PER SKIPPED MONTH will be CHARGED accordingly but
the amount will be deducted from your TOTAL BRACES PACKAGE and IS NOT CONSIDERED AS AN ADDITIONAL FEE.
• Should the patient decide NOT TO CONTINUE the treatment after installation, payment made will be forfeited or not refundable.
• Should the patient request for referral or recommendation letter for transfer, total balance has to be settled first to process the said
request.
• In the meantime, patient must avoid eating hard solid foods like, peanuts, hard candies, caramel, chips, ice cubes, corn kernel,
chewing gums, bagels, and other hard rolls, popcorn, pizza crust, crunchy vegetables and fruits, pretzels, spicy foods, thick rolls or
breads, and thicker cuts of meats.
• Should the bracket be removed within 3 days after the installation or adjustment, 1-2 brackets removed will not incur additional
charge should the patient be able to pay a visit within 3 days that the bracket(s) has been removed. Failure to do will result to an
additional fee per LOST BRACKET:
o P500 (METAL BRACES)
o P700 (CERAMIC)
o P1000 (SELF-LIGATING), and P200 per REMOVED BRACKET.
• Non-compliance may result in delay of treatment progress.

To confirm your understanding of this agreement, please sign below:

______________________________________________________________ ___________________________________
Patient Name and Signature Date

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