• Orthodontic Financial Agreement Form

    Please complete this form to confirm your orthodontic payment arrangement and financial responsibility before treatment begins.

  • Patient and Responsible Party Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Preferred Contact Method*

  • Treatment and Account Details

  • Treatment Start Date / Planned Start Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Will Insurance Be Billed/Assigned?*

  • Payment Arrangement

  • Chosen Payment Plan*
  • Payment Due Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Preferred Payment Method*
  • Automatic Payment Authorization and Late Fee Acknowledgment*

  • Financial Agreement and Signature

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  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty:
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