As a condition of treatment by this office, I understand financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency orthodontic services, or any orthodontic service performed without prior financial arrangements, must be paid for in cash at the time services are performed. I understand that orthodontic services furnished to me are charged directly to me and that I am personally responsible for payment of all orthodontic services. I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from my insurance companies and will credit such collections to my account. However, AO cannot render services on the assumption that charges will be paid by an insurance company.

Assignment of Insurance: I hereby authorize my insurance company to pay directly to my Orthodontist benefits accruing to me under my policy. A bookkeeping fee of $150/month will be charged on the unpaid principal balance on all accounts not paid within 30 days of treatment date. I understand that the fee estimate listed for this orthodontic service can only be extended for a period of six months from the date of the patient’s examination. In consideration of the professional services rendered to me, or at my request , by the Doctor and/or by his staff, I agree to pay, therefore, the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered. I furthermore agree that the reasonable value or said services shall be billed unless objected to by me, in writing, within the time of paying thereof. Additionally, I agree that a waiver for any breach of any term or condition hereunder shall not constitute a waiver of any further term or condition. I further agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceedings shall be entitled to recover all costs incurred including reasonable attorney’s and/or collection fees.

I consent to the use of my testimonials and pictures, if taken, to be only used for marketing purposes only. I may cancel this authorization in writing to your office.

I have read the above conditions of treatment and agree to their content.