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Payment Options
Date:
01/19/2007
INVESTMENT OPTIONS
Thank you for selecting us for your orthodontic care! Your ideal smile will make all the difference in the most important of circumstances and we are excited for you to receive the truly unlimited value of orthodontic treatment. Because we do not want financial concerns to stand in the way, we are pleased to provide the following payment options which are valid for the next 120 days.
Estimated Fees
Patient Name:
Cookie Doe
Responsible Party:
Cookie Doe
Estimated Length of Treatment:
18
Months
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
OPTION 1 -
PAYMENT IN FULL
Estimated Patient Balance
$
4185
5% Pay in full credit
(
209.25
)
Payment in Full
$
3975.75
OPTION 2 -
INTEREST FREE
Estimated Patient Balance
$
4185
Initial Investment:
(
837
)
Balance:
$
3348
Monthly Investment:
$
240
Months:
14
Last Payment:
$
228
OPTION 3 -
LOW DOWN, LOW MONTHLY
Estimated Patient Balance
$
4185
Initial Investment:
(
300
)
Balance:
$
3885
Monthly Investment:
$
194.93
Months:
22
Note 1: The insurance amount is an estimate only and any benefit not actually paid by insurance will be incorporated into the contract.
Note 2: Options 2 and 3 require monthly payments to be made via Automatic Drafts or Electronic Fund Transfers from a checking account, savings account, credit card, or debit card.
Note 3: Option 3 includes a service charge of 10%. A lower down payment, service charge, and monthly payment may be obtained with credit history.
Phone: 866-Acceptx Website: www.Acceptx.com Address: 5594 S. Fort Apache Rd, Las Vegas, NV 89148
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