ORTHODONTIC FINANCIAL AGREEMENT

ORTHODONTIC FINANCIAL AGREEMENT
Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Financially Responsible Party Name*

First NameLast Name
Professional Treatment Fee*
Professional Courtesy*
Other professional courtesy
Insurance Benefit sent to subscriber
Less Insurance Benefit*
Estimated Responsible Party Portion*
Less Initial Investment*
Unpaid Balance
Unpaid balance is payable to Bergen Orthodontics in blanks monthly installments of $ blank each, and one installment of the remaining balance. The first installment is payable on and subsequent installments on the same day of each consecutive month until paid in full. A $10 late fee will be charged on all accounts that are ten days past due.
Signed by Financially Responsible Party

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Date*

MonthDayYear
Date
Signed by Witness

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Date*

MonthDayYear
Date
Today's Date

My Products

USDDescription

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country