Orthodontic Financial Agreement Form

Patient Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Orthodontist / Office Name

Responsible Party Full Name

First NameMiddle NameLast Name

Relationship to Patient

Email Address

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Billing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Preferred Contact Method

Treatment Start Date / Planned Start Date

Date

Total Treatment Fee

Estimated Insurance Contribution

Account / Case Number

Will Insurance Be Billed/Assigned?

Chosen Payment Plan

Other Office-Approved Arrangement

Down Payment Amount

Recurring Payment Amount

Payment Due Date

Date

Preferred Payment Method

Automatic Payment Authorization and Late Fee Acknowledgment

Responsible Party Signature

Date