Financial Agreement / Treatment Consent

Financial Agreement / Treatment Consent

Bayside and Countryside Orthodontists
Patients Name

First NameLast Name
Date

DayMonthYear
Date
Type a question

Other
Total Treatment Fee:
Payment Option

DEPOSIT and MONTHLY INSTALMENTS. 🏦 via third party provider. Monthly instalments during treatment time with an initial deposit prior to treatment start. Denticare is our third party financial providers, with minimal fee charges and you can vary the payment amount and frequency. We will email/ sms you a link to set up your credit card/bank account details.
Other Payment Option not listed above:
Please indicate your preferred payment option and the financial team will review your request and advise.
Denticare Fee Disclosure: Account set up fee $49 (once only), $1.10 Transaction Fee (bank account) 1.75% surcharge on credit/debit cards, Failed Payment Fee from $16.50 up to $38.50. $9.90 amendment fee.
Initial
How would you like to pay the Denticare instalments?
Consent to Treatment I hereby authorise Bayside/Countryside Orthodontists to carry out orthodontic treatment and any other related procedures deemed necessary for the welfare and treatment of the above mentioned patient. I confirm that the risks attached to the proposed treatment have been explained to me by my practitioner and that I fully understand those risks and have determined to proceed with treatment.
Initial
I/We have read and agree to orthodontic treatment as outlined in the financial contract provided separately, and give consent for the orthodontic appliances to be ordered and treatment to commence.
Initial
Responsible Party Signature

First NameLast Name
Responsible Party Date of Birth

DayMonthYear
Date
Signature
Your digital signature via this link is sufficient, we do not require a copy of the signed contract.

We will send you an invoice or the ezidebit / denticare link, once your digital signature has been received.

Bank account details:
Account name: Bayside Orthodontists

BSB: 083 028

ACCOUNT NUMBER : 73201 6534

REFERENCE : “Patient Surname”

Please email your remittance to info@braces120.com
Should be Empty: