Honest Communication Appointment Policy

Honest Communication Appointment Policy

APPOINTMENT POLICY Many parents work and most children attend school. In order to be fair to everyone we ask that you alternate the before and after school appointments with mid-day appointments for our more detailed procedures, this translates to a midday appointment approximately once every 3-4 months.

COMMITMENT TO KEEPING APPOINTMENTS AND WEARING APPLIANCES I understand that treatment has been or could be extended due to missed appointments and/or lack of compliance with aligners, elastics or excessive broken appliances. I commit to keeping regularly scheduled appointments and consistent appliance compliance. I am aware that discontinuation of treatment may be suggested if there are any future compliance concerns.
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Financial Policy

THIS FINANCIAL POLICY is in effect for Orthodontic treatment to be completed within the agreed upon time frame. There will be a Retention Phase of treatment that will take 12 months once treatment is completed. Our contracts are paid on a monthly basis, should monthly payments cease to be made regularly, that is considered breach of contract and the patient is at risk of being dismissed from the practice.

IF TREATMENT IS EXTENDED beyond 6 month, due to lack of cooperation or traumatic injury, there may be an extra monthly charge until the braces are removed. The monthly charge is now $175, but may differ in the future. IF THERE IS EXCESSIVE BREAKAGE of the braces, or loss of removable appliances, retainers, et cetera, there may be additional repair or replacement charges, to be determined at that time.
Name of Responsible Party/Patient

First NameLast Name
Date

MonthDayYear
Date
Signature

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Honest Communication Appointment Policy

Financial Policy