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7695 Cardinal Court, Suite 320 San Diego, CA 92123 T 858.277.8080 F 858.277.8090 www.DrEhsani.comORTHODONTIC TREATMENT FINANCIAL AGREEMENT Disclosure statement and agreement for the professional services
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How to fill out orthodontic treatment financial agreement

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How to fill out orthodontic treatment financial agreement

01
Start by gathering all relevant information, such as the orthodontic treatment plan and cost details.
02
Contact the orthodontic clinic or office where the treatment will take place to obtain a copy of the financial agreement form.
03
Read through the financial agreement form carefully, paying close attention to the terms and conditions, payment schedule, and any additional fees or charges.
04
Fill in your personal information, including your name, address, contact details, and insurance information, if applicable.
05
Specify the details of the orthodontic treatment, such as the type of braces or aligners being used.
06
Provide information about the expected timeline for the treatment, including the start date and estimated duration.
07
Review the payment options available to you, such as paying in full or setting up a payment plan.
08
Indicate your preferred payment method, whether it's by check, credit card, or electronic bank transfer.
09
Sign and date the financial agreement form, acknowledging your understanding and acceptance of the terms and conditions.
10
Make a copy of the completed form for your records, and submit the original to the orthodontic clinic or office.

Who needs orthodontic treatment financial agreement?

01
Anyone who is undergoing orthodontic treatment and is responsible for covering the associated costs needs an orthodontic treatment financial agreement.
02
This may include patients who are getting braces, Invisalign, retainers, or any other orthodontic appliances.
03
The financial agreement serves as a contract between the orthodontic provider and the patient, outlining the financial obligations and payment terms.
04
It ensures that both parties are on the same page regarding the cost of the treatment, payment arrangements, and any additional fees or charges.
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Orthodontic treatment financial agreement is a written agreement outlining the financial terms and responsibilities for orthodontic treatment.
The patient or responsible party is required to file the orthodontic treatment financial agreement.
To fill out the orthodontic treatment financial agreement, you need to provide personal information, treatment details, payment terms, and signatures.
The purpose of orthodontic treatment financial agreement is to establish clear expectations and obligations regarding the cost of orthodontic treatment.
The orthodontic treatment financial agreement must include patient's name, treatment plan, total cost, payment schedule, and terms and conditions.
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