Because we, Local Orthodontics, and you as the Responsible Party both desire a successful course of orthodontic treatment, the following information is designed to be mutually beneficial to both the patients and our staff as policy issues arise.

PAYMENT PLAN: Orthodontic fees are paid on a monthly basis. For your convenience, there are several payment methods available. In order that we may have a definite understanding regarding the payment of the orthodontic fees, please choose one of the following: We are happy to accept cash, personal checks, money orders or major credit card for payments, Please be reminded that consecutive month payments are due regardless of scheduled appointments. Payment books will be provided for your convenience.

• M o n t h l y M a i l - i n P l a n : ​Payment​ ​book will be provided for your convenience.
• A u t o m a t i c C h a r g e C a r d : ​ Monthly Payments will automatically be charged to your Visa, Mastercard, or Discover on the 1st or 15th (please specify)
• C a s h D i s c o u n t O p t i o n : ​Discount will apply if the account is paid in full within 30 days of the initial banding appointment.
• There is no down payment towards your braces. Your are expected to make your first monthly payment the day the braces are placed.
• Statements of the accounts are issued for delinquent accounts. Payments are due by the first of each month to ensure your account is posted as current. A late fee of $25 will be assessed if payment is not received by the 15th of the month. Accounts which become delinquent will result in the discontinuation of active treatment.
• Insurance plans such as Denticare, Guardian, Cigna or any plan that allows members to receive a reduced fee for treatment must be presented to the Financial Supervisor prior to your records appointment.  Contracts will not be rewritten after beginning treatment.
• If Insurance is applicable, you have read and received a copy of the Insurance Policies form. Once we have received approval, then your monthly payments will be adjusted until your account is paid in full.
• We do allow one inter office transfer. If you elect multiple transfers, your account will be assessed a $50 handling fee.
• Returned checks will result in a $25 charge to your account. Only cash or credit card payments will then be accepted.
• Discontinuation of treatment, or transfer from our practice, will result in assessment charge based on fees due for services rendered.
• The balance of your account, including payment for retainers, is due at the time the braces are removed. You are aware of the option to pay for retainers monthly during the course of the patient's treatment.
• Any cost associated with the collection of your contract will be paid by the responsible party.

II. OFFICE PROCEDURES AND POLICIES.

• Each Patient's treatment is on an individual basis. Appointments vary from 4-12 weeks apart.
• After school appointments are alternated with school time appointments, usually on a 2 for 1 basis. The patient's schedule will be accommodated if at all possible.
• Missed appointments will result in a $35 charge to your account, and can  prolong treatment.
• Lack of cooperation by the patient(such as poor brushing, not wearing rubber bands, etc.) and continually missing appointments), may result in prolonged treatment time and additional charges. Braces can cause permanent damage to teeth without the care and supervision of an orthodontist. Cooperation by the patient is necessary to protect the teeth and gums from permanent damage. The patient/parent is responsible for maintaining good cooperation and a consistent appointment schedule in order to ensure that no damage occurs.
• Phase One Treatment: Future treatment may be required for Phase II.
  A cleaning exam, along with necessary fillings, must be completed before the braces are placed. It is your responsibility to keep regular 6 month check ups with the dentist. This check up must include a thorough examination of the periodontium(gum tissues).
• The patient's teeth need to be brushed before the orthodontic appointment. Toothbrushes and toothpaste are provided.
• Reports and written communications are given to our patients on their progress appointments. In the event you do not accompany your child, these documents will be given to the patient to be delivered to you.
  
• I understand all State and Federal OSHA regulations are strictly adhered to.
• I, as the Responsible Party, acknowledge that a staff member has gone over all of the information with me, and that I understand it completely.