Gardens Orthodontics Practice Guidelines
Insurance: We will assist in the filing of insurance claims so that you might receive the full benefit available from your insurance company. We file your insurance as a courtesy. If for ANY reason, insurance payments are not received, the remaining insurance balance becomes your responsibility. We cannot be held responsible for knowing all the limitations of all of the insurance companies we deal with. It is your responsibility to become familiar with your own policy. If there is a limitation about your insurance company of which you do not inform us, and it results in an underpayment of benefits, we will not be held responsible. All insurance payments must be paid in full prior to removal of appliances. Please be advised that insurance payments are received within the span of your treatment time.
The professional fee is charged for active treatment and includes adjustment appointments, appliances mentioned in the treatment plan, retention. The professional fee may not include certain diagnostic records taken for treatment planning. The professional fee does NOT include any general dental treatment that may be required such as extractions, fillings, cleanings, etc or any services of other dental professionals.
Treatment time: total treatment time is an estimation and may be subject to change. In the event of early termination of treatment by patient, patient/responsible party’s consent is required and the contract balance must be paid in full.
Appointment: In an unforeseen circumstance that you are unable to keep an appointment, please call us as soon as possible but no later than 24 hours prior to the appointment. Broken or canceled appointments may result in longer treatment time and/or a $25 charge. For any broken appointment that needs to be rescheduled, it will be done between 10 am – 2:30 pm. All failed or late appointments must be rescheduled within one week of the original appointment.
The professional fee does not include replacement of lost/broken appliances or broken brackets. Excessive breakage of brackets, bands and/or wires will results in additional charges per occurrence. We reserve the right to charge $25 for any broken brackets after the third occurrence.
Dental exam/follow up: we require a clearance letter from your dentist prior to start of Orthodontics. When orthodontic treatment begins, patient shall be required to visit his/her dentist every 3–6 months for dental exams and cleanings. It is routine for the dentist to complete cavity checks during your dental exams.
Installments: payment of the professional fee in installments has been permitted by doctor for convenience and as a courtesy. The amount of monthly installments does not correlate to the treatment received.
Recurring Installments: Payment shall be due in accordance with the installment plan described on the contract. I authorize recurring ACH charges outlined in the contract. I understand that the authorization will remain in effect until I cancel it in writing. I shall notify the practice in writing of any changes in my account information or termination of this authorization at least 15 days prior to the next billing date. If patient or responsible party does not pay any installments within ten (10) days after the monthly installment date, late fee of $10 shall be charged monthly.
Patient Cooperation: Cooperation in orthodontic treatment is a must. When a patient’s failure to keep appointments, or follow instructions begin to adversely affect the orthodontist’s ability to treat the patient, the patient and or parent may be required to appear for a consultation with the orthodontist. If in the Orthodontist‘s opinion, the patient’s cooperation does not improve, treatment may be terminated and patient dismissed. Patient will remain financially responsible for the cost of total treatment. Patient cooperation with keeping timely appointments, oral hygiene compliance, diet restrictions to avoid breakage of brackets and appliances, elastic wear and aligner wear as prescribed are directly correlated to the success of the outcomes. Failure to do so may result in additional treatment time and charges.
No waiver by Dr. of any breach or default by patient or responsible party shall constitute a waiver of any additional or subsequent breach or default by patient or responsible party. Failure to timely pay the installments when do shall entitle doctor to terminate this agreement and to pursue any and all remedies permitted here under or by law in collection of all monies due doctor, including the right to accelerate the maturity of the balance due here under and require the payment thereof in full. In the event of acceleration, all monies due Dr. shall accrue interest from the date of acceleration until paid at the highest rate allowed by law. In the event any litigation arises out of the contract, patient and responsible party agree that venue shall lie in Palm Beach County, Florida. In the event of any default and payment hereunder, Doctor shall be entitled to recover all costs of collection incurred in the enforcement of this agreement, including but not limited to, responsible attorneys fees and court costs incurred in the enforcement of this agreement, including but not limited to, reasonable attorneys fees and court costs incurred in the enforcement of this agreement and the collection of any unpaid moneys do doctor. Dr. Shall also be entitled to recover reasonable attorneys fees incurred in any post judgment proceedings, including appeals, actions for collection of judgment, or action to preserve any monies due doctor, weather pending in state, federal or bankruptcy court.
In the event that patient is a minor, responsible party shall be liable to pay all sums due hereunder, including all costs of collection described herein. If patient is not a minor, then responsible parties shall be jointly and severely liable with patient here under, including all such costs of collection.
Patient, responsible party and Dr. hereby waive any and all rights to a trial by jury that each may have in regards to any litigation, including any counter claim which patient may assert, that arises out of, or is founded upon or is in any manner connected with, the subject matter of disagreement, any course of conduct, course of dealing, statements (whether a verbal or written) made by either party, or any actions of either party with respect here too. Patient, responsible party and doctor for the waive any right to claim punitive or exemplary damages against the other.
I give consent for my child/self to doctors to do whatever procedure they deem necessary to achieve the objectives and benefits from this indicated orthodontic treatment.
Name
*
First Name
Middle Name
Last Name
Responsible Party Name:
*
First Name
Last Name
Signature of Responsible Party:
*
Date:
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: