Info Package for Jordan

ORTHODONTIC TREATMENT QUOTATION

Date: 28 January 2016
Treatment plan for - Jordan Smith
Provider: Fiona M Hall - 2167214J

Orthodontic Services Completed today: no charge
012 Orthodontic Review no charge
073 Clinical Photos (Extra-Oral) no charge
072 Clinical Photos (Intra-Oral)

Proposed Appliance Treatment Plan

071X2 Diagnostic Models $96.00
$1210.00
821 Active Removable Appliance

*This fee is inclusive of all supervised visits, adjustments and repairs (within reason).

Please remember, separate charges will be levied by your general dentist for
fillings, extractions, etc, that may be required prior, during or after treatment.
Additional xrays may be required and additional fluoride applications may be required if
oral hygiene is below standard. Both will attract additional fees. This quotation becomes
void if treatment is not commenced within three months of the date stated above. This
quotation becomes void if the terms of payment are not met. Treatment can be
terminated if cooperation with treatment is not forthcoming and/or the financial
obligations by the parents/patient are not acceptable as per pre-treatment agreement.
Payment must be complete before appliance removal. If there is any aspect of this
quotation or the proposed treatment, which you are not totally clear about, or if
there is anything you would like to discuss further, contact the practice so we
may discuss and clarify your concerns

CONSENT AND FINANCIAL AGREEMENT

Dear Ms. Joanne Smith,

Your quotation has been calculated on the type of appliance required, length of treatment
and the duration of payment. The minimum conditions of payment are:-

1. Removable appliances such as a Upper Removable Appliance (URA) are quoted
on payment of a deposit of ($310) prior to placement of the appliance followed by
three (3) monthly payments of ($300) per month. All payment plans in the practice
are interest free if paid regularly.

Payments are due on the monthly anniversary of appliance placement.

If you wish to avoid a payment plan as described above, payment of the full fee at
appliance insertion or placement attracts a 5% reduction if paid by cash, cheque or eftpos
and a 2% reduction if paid by credit card. If you choose to pay by EFT, payment has to
be processed three (3) business days prior to placement of appliance (s). Bank
account details will be provided upon request.

If you choose the deposit and payment plan option and intend to pay by EFT, your deposit is
required to be paid three (3) business days prior to appliance placement and then monthly
instalments can continue to be paid by the anniversary date of appliance placement.

If you have private health insurance for dental/orthodontic cover, please claim your health
fund rebate immediately, the deposit and the difference (if any) must be paid by yourself
at the surgery within 7 days of appliance fitting or placement.

All health insurance funds have different methods of calculating your rebate, so
please discuss your quotation with them prior to commencing treatment, so you
are fully informed as to your entitlements. Please remember it is your Health Fund
and not ours, although we will obviously help you with all the details you will
require.

If you do not have private health insurance your deposit is required at appliance
fitting or placement.

Please advise our front office co-ordinators in advance which option you wish to
nominate.

CONSENT

I have read and understand the information supplied to us and accept the written
quotation. I guarantee to adhere to the payment plan and all conditions outlined in the
quotation. I also accept that a surcharge of 5% of the quotation plus any debt collection
agency fees including associated legal costs will be charged if our payment plan is not
adhered to.

I consent for Jordan Smith to undergo Orthodontic treatment.

Ms. Joanne Smith

Signature………….………………………………………………………

Date ……………………………………………………