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FINANCIAL AGREEMENT
Date:
01/19/2007
You have already signed on this document
FINANCIAL AGREEMENT
We are excited to create an ideal smile. Below are the details of the financial arrangement you have chosen. By signing this contract you are agreeing to comply with the terms outlined below. You will receive a signed copy of this contract and we will maintain the original on file.
Estimated Fees
Patient:
Cookie Doe
Responsible Party:
Cookie Doe
Estimated Length of Treatment:
18
Case Fee:
$
5,085.00
Estimated Insurance:
$
1,500.00
(-)
Sub Total:
$
3,585.00
On Time Bonus:
$50.00
(-)
Sub Total:
$3,535.00
Clear Braces:
$650.00
(+)
Estimated Patient Balance:
$
4,185.00
I agree that the insurance amount is an estimate only and that I am personally responsible for any balance not paid by my insurance.
The full case fee above does not cover extractions, exposures, or any other treatment rendered and/or required by other dentists, dental specialists, or other healthcare providers.
OPTION 3 - (LOW DOWN, LOW MONTHLY PAYMENT PLAN)
Option 3 - (Low Down, Low Monthly Payment Plan)
Estimated Patient Balance:
$
4,185.00
Initial Investment:
$
300.00
Balance:
$
3,885.00
Monthly Investment:
$
194.93
Months:
22
Last Payment:
$
194.93
Total Payments:
$
4,288.46
Witness Signature: _____________________________
Signed: _____________________________
Cookie Doe
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