Orthodontic Treatment Contract

Orthodontic Treatment Contract
This agreement is made this
between
(responsible party) and Franklin Orthodontics, PLLC, for orthodontic services to be performed on
(patient).
The fee for orthodontic services is $
. This fee includes diagnostic records (all x-rays, photographs and study models), case analysis and consultation, orthodontic appliance insertion, active treatment visits with 6 months of treatment overrun, appliance removal, placement of appropriate retention devices and retention follow-up visits for 12 months. Franklin Orthodontics, PLLC agrees to provide orthodontic services to the patient, and the patient/responsible party agrees to pay for these services in the amount above.
Federal Truth in Lending Disclosure Statement
Lender
Patient Name
First Last
Borrower(s) Name
First Last
Borrower(s) Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date
Date Format: MM slash DD slash YYYY
Fee for Orthodontic Services (total sale price)
Less Initial Down Payment
Less Discounts/Credits
Less Estimated Insurance Benefit
Total Amount Financed (amount of credit provided to you or on your behalf)
Annual Percentage Rate (APR) (the cost of your credit as a yearly rate)
Finance Charge (the dollar amount the credit will cost you)
Total Repayment to Lender (amount you will have paid when all payments are made on time)
Monthly Repayment Schedule
Number of Payments:
Amount of Each Payment: $
Due Date of Each Payment:
Final Monthly Payment (if different): $
First Payment Date:
Final Payment Date:
The frequency of payments to be made by the patient/responsible party is not related to the frequency of the treatment visits, nor to the length of orthodontic treatment. The installment payment plan is established only as a convenience to you.

As long as each and every payment is made as it comes due, no additional interest will be charged. Additionally, no monthly statements will be sent to the patient/responsible party, but a coupon book for payments may be issued upon request.

If a monthly payment becomes 27 days past due, Franklin Orthodontics, PLLC may charge a $10.00 fee per month in which the account remains past due. In the event that Franklin Orthodontics, PLLC must seek action for collection, patient/responsible party agrees to be liable for all collection/attorney’s fees, the outstanding balance, a processing fee of 33% of the outstanding balance, and all interest charges, late fees, and court costs.

The fee quoted above covers all routine orthodontic appliances and appointments. All general dental procedures (i.e. extractions, cleanings, restorations, surgeries, composite buildups, crowns, prosthetic appliances, etc.) are not included within the orthodontic fee. Any complications extending treatment unnecessarily (poor patient cooperation, missed appointments, lost or damaged appliances, excessive breakage, etc.) will require a reevaluation of the initial fee and possibly necessitate additional charges to cover the increased expenses for treatment. These changes will be discussed prior to being charged.

In the event treatment is terminated before completion of planned services, the balance due or refund due will be calculated according to the work completed.

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Orthodontic Treatment Contract

Federal Truth in Lending Disclosure Statement

Monthly Repayment Schedule