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Get Great Whites Pediatric Dentistry & Orthodontics Contract for Orthodontic Treatment

D. S. 755 PARK AVE SUITE 180 HUNTINGTON NY 11743 631-261-5100 Contract for Orthodontic Treatment THE FOLLOWING IS AN AGREEMENT FOR ORTHODONTIC TREATMENT FOR PATIENTDATE PLEASE READ THIS EXPLANATION CAREFULLY. GREAT WHITES PEDIATRIC DENTISTRY ORTHODONTICS DAWN SOSNICK D. D. S* REGINA HENDRICKS D. D. S* MARIKA CHIKVASHVILI D. FEEL FREE TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THE TREATMENT OR FINANCES* FEES THE TOTAL FEE FOR ORTHODONTIC TREATMENT IS 1 INSURANCE BENEFIT 2 INITIAL FEE 3 MONTHLY FEE THE INITIAL FEE IS DUE WHEN APPLIANCES ARE PLACED. THE MONTHLY FEE IS DUE BY THE 10TH OF EACH MONTH. OFFICE POLICY REQUIRES THAT AN ACCOUNT HAVE NO OUTSTANDING BALANCE PRIOR TO THE REMOVAL OF APPLIANCES* THIS PAYMENT PLAN HAS BEEN DEVISED FOR YOUR CONVENIENCE* THE FREQUENCY OF VISITS HAS NO BEARING ON THE PAYMENT SCHEDULE* WHAT THIS COVERS THE FEE FOR ORTHODONTIC SERVICES COVERS THE ACTIVE TOOTH MOVEMENT PHASE OF ORTHODONTIC TREATMENT. THIS USUALLY RUNS FROM TWELVE TO TWENTY-FOUR MONTHS* IN ADDITION THE FEE COVERS TWELVE MONTHS OF RETENTION AND OBSERVATIONS* WHAT THIS DOES NOT COVER ADDITIONAL FEES WILL BE INCURRED FOR CLEAR BRACES EXCESSIVE BROKEN BRACES BROKEN APPOINTMENTS WITHOUT 24 HOURS NOTICE LOST OR BROKEN APPLIANCES e*g* HEAD GEAR RETAINER UNPREDICTABLE GROWTH COMPLICATIONS REQUIRING EXTENDED TREATMENT ORTHODONTIC INSURANCE THE PATIENT OR RESPONSIBLE PARTY IS SOLELY RESPONSIBLE FOR TREATMENT FEES* INSURANCE IS ACCEPTED AS PARTIAL PAYMENT. THIS FORM ESTIMATES YOUR INSURANCE BENEFIT FOR YOUR CONVENIENCE* IF YOUR INSURANCE IS LESS THAN ESTIMATED OR IS CANCELLED ANY TIME DURING TREATMENT YOU WILL BE RESPONSIBLE FOR ANY OUTSTANDING BALANCE ON YOUR ACCOUNT. FEEL FREE TO ASK ANY QUESTIONS YOU MAY HAVE ABOUT THE TREATMENT OR FINANCES* FEES THE TOTAL FEE FOR ORTHODONTIC TREATMENT IS 1 INSURANCE BENEFIT 2 INITIAL FEE 3 MONTHLY FEE THE INITIAL FEE IS DUE WHEN APPLIANCES ARE PLACED. THE MONTHLY FEE IS DUE BY THE 10TH OF EACH MONTH. OFFICE POLICY REQUIRES THAT AN ACCOUNT HAVE NO OUTSTANDING BALANCE PRIOR TO THE REMOVAL OF APPLIANCES* THIS PAYMENT PLAN HAS BEEN DEVISED FOR YOUR CONVENIENCE* THE FREQUENCY OF VISITS HAS NO BEARING ON THE PAYMENT SCHEDULE* WHAT THIS COVERS THE FEE FOR ORTHODONTIC SERVICES COVERS THE ACTIVE TOOTH MOVEMENT PHASE OF ORTHODONTIC TREATMENT. THE MONTHLY FEE IS DUE BY THE 10TH OF EACH MONTH. OFFICE POLICY REQUIRES THAT AN ACCOUNT HAVE NO OUTSTANDING BALANCE PRIOR TO THE REMOVAL OF APPLIANCES* THIS PAYMENT PLAN HAS BEEN DEVISED FOR YOUR CONVENIENCE* THE FREQUENCY OF VISITS HAS NO BEARING ON THE PAYMENT SCHEDULE* WHAT THIS COVERS THE FEE FOR ORTHODONTIC SERVICES COVERS THE ACTIVE TOOTH MOVEMENT PHASE OF ORTHODONTIC TREATMENT. THIS USUALLY RUNS FROM TWELVE TO TWENTY-FOUR MONTHS* IN ADDITION THE FEE COVERS TWELVE MONTHS OF RETENTION AND OBSERVATIONS* WHAT THIS DOES NOT COVER ADDITIONAL FEES WILL BE INCURRED FOR CLEAR BRACES EXCESSIVE BROKEN BRACES BROKEN APPOINTMENTS WITHOUT 24 HOURS NOTICE LOST OR BROKEN APPLIANCES e*g* HEAD GEAR RETAINER UNPREDICTABLE GROWTH COMPLICATIONS REQUIRING EXTENDED TREATMENT ORTHODONTIC INSURANCE THE PATIENT OR RESPONSIBLE PARTY IS SOLELY RESPONSIBLE FOR TREATMENT FEES* INSURANCE IS ACCEPTED AS PARTIAL PAYMENT. .

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