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Orthodontic Agreement

 

Patient Name: ___________________________________________________

Total Treatment Fee: _______________________________________

$_______________ due at Initial Appointment and $_______________ due monthly.

Please initial ________

The fee includes orthodontic treatment as well as 1 year retention which includes one retainer per arch. Additional charges will be applied for lost or broken appliance due to

negligence.

Please initial ________

After the first broken appointment, a $40.00 fee will be applied to the account for failed appointments or appointments cancelled without 48 hours notice.

Please initial ________

During the first month broken brackets are fixed with no fee. After 1 completed month of treatment a $25.00 fee will be charged for each broken bracket.

Please initial ________

The fee does not include any general dentistry, cleaning, X-rays, TMJ treatment, oral surgery (including extractions needed for orthodontic treatment).
Please initial ________

A charge of $75.00 per month will be made for treatment that extends past 3 months due to poor cooperation. Your estimated treatment time will be between ____________.

Please initial ________

Broken brackets may need to be fixed during school hours. We will do our best to schedule appointments that are not during school hours. These are the most popular appointment times and fill-up very quickly.

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Successful orthodontic treatment can be brought about only through the cooperation of all parties involved. Arriving at the office on time for appointments, having the patient take excellent care of his/her teeth during the treatment phases and wearing all appliances with excellent cooperation will go far to help us succeed in reaching the orthodontic goals envisioned at the start. If the patient does not wear all appliances prescribed exactly as instructed, success of the orthodontic therapy and length of the orthodontic therapy will be negatively affected.

Please initial ________

If the removable or fixed orthodontic appliance repeatedly breaks or is lost a charge will incur. Decalcification (permanent markings on the teeth), tooth decay or gum disease can occur during orthodontic therapy if patients do not brush and floss their teeth properly as instructed.If home care does not reach the acceptable standard we may suggest that the braces should be removed early and treatment discontinued.

Please initial ________

At the end of active treatment we will discuss the result that has been achieved, and if we both are happy, we will remove the braces and fit retainers.

A retainer will need to be worn full time for 12 months when orthodontic treatment is finished to keep the teeth straight. After these 12 months are over the retainer should be worn only at night while sleeping... for ever. A retainer has to be worn as prescribed if not there WILL be a relapse which results in disappointment. The responsibility for the future position of the teeth depends on wearing the retainer long term.

Please initial ________

The office of Dr. Miskin reserves the right to discontinue treatment and remove braces early if failure to adhere to the financial arrangements occurs, if appointments are repeatedly missed and if home care does not reach the acceptable standard.

Please initial ________

I have read and hereby certify that I understand my responsibilities and agree to this financial agreement.

Signature of responsible party _________________________ Date ______________