Siraj R. Baig, DDS, PC & Associates

 

Ortho Consent Form

 

Date: 04-26-2024
Patient Name:


The dental practice of Dr. Siraj Baig to provide orthodontic care to patient is expected to take months. The initial banding fee of upper, lower. The treatment fee will be $/month for months.
It is understood that the full amount (total fee) is due before removal of orthodontic appliances, no matter what the reason to discontinue treatment. No interest will be charged unless any payment becomes overdue by days, at which time a penalty of will be added to the treatment fee.
The above orthodontic fee does not include fees for the following:

1. Extractions
2. Retention
3. Tooth Clening
4. X-rays taken during orthodontic treatment
5. Bridges
6. Crowns
7. Dental Fillings
8. Possible Bonding or Veneers after orthodontics
9. Initial Orthodontic Records
10. Final Orthodontic Records
11. Fiberotomy
12. Corticotomy
13. Gingival Grafts
14. Cosmetic Gingivectomy
15. Ceramic Brackets
16. Plastic Brackets
17. Other

It is expected that the patient will maintain their orthodontic appliances during the treatment time. In the vent of breakage or loss of an appliance, an extra fee will be charged for its repair or replacement. These may include:

1. functional appliance
2. orthodontic brackets
3. retainers
4. headgear and/or facebow
5. archwires
6. other

If the patient moves out of the area before orthodontic treatment is completed, a determination of the fee for service rendered to date will be made. This amount will be the sum of the initial banding fee plus the number of treatments visit made to the practice at the rate determined in the above calculation. The financing arrangement does not in any way determine the fee for services at any one time during the treatment period.
The fee determined by this agreement will be due upon transfer. If the fee is not paid then the initial records and the transfer letter will not be sent to the subsequent treating doctor without the payment in advance for the duplication of the record plus for the transfer letter. It is understood that changing treating dentists almost always result in longer treatment time and higher overall fees for the treatment.
The person(s) responsible for payment of this account agree to the above terms and conditions.


Patient or Representative Signature