RCDG - Invisalign Agreement ($6,000 / 12 months)

Your Invisalign Agreement
This is your fee estimate for the recommended services you discussed with our provider. These services and fees may vary during treatment due to unforeseen factors.

Total cost for Invisalign: $6,000.00

Financial Arrangement

Initial Payment: $2,000.00 ($300.00 Invisalign records fee + $1,700.00) is paid upon Patient's receipt of their case and have decided to proceed.

Remaining balance: $4,000.00 is paid over ten (10) months, in monthly installments of $400.00 each.

NOTE: Changes in coverage or limitations will affect this financial arrangement.

Clinic Appointment Policy

We require 48 hours' notice to reschedule appointments. Failure to provide sufficient notice in the event of a cancellation may result in the charge of $100 per hour for the clinical team's time.

This estimate is valid for 90 days.
Patient's Name*

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Date of Birth*

MonthDayYear
Date
I sign on my own behalf, attesting that the above treatment has been explained to us. We understand the benefits and risks and have no further questions at this time.*

Clear
As Guardian/Representative of the above name minor Patient, I sign on their behalf, attesting that the above treatment has been explained to us. We understand the benefits and risks and have no further questions at this time.*

Clear
Date Signed*

MonthDayYear
Date
ROYAL CENTRE DENTAL GROUP
210-1055 West Georgia Street Phone: 604-683-8100
Vancouver, BC V6E 3P1 eMail: info@rcdg.ca
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Your Invisalign Agreement