Call: (248)471-5534


Siraj R. Baig, DDS, PC & Associates

Dr. Siraj Baig, DDS, PC & Associates

23304 Orchard Lake Rd, Farmington Hills, MI 48336
Phone Number: 248-471-5534
Email: Sirajbaigdds@yahoo.com
Website: www.sirajbaigdds.com

 

Orthodontic Form

 

04-22-2018


The following is an agreement for orthodontic treatment.
The total fee for the Orthodontic Treatment is $
$

The initial fee is due when the appliances are placed. The monthly fee is due at the time of your appointment, or we are able to automatically charge the credit card of your choosing the first week of the month. All payments must be completed prior to the removal of the appliances.
Please be informed that treatment has the following possible risk:

  1. Root Resorption
  2. Bone or tooth loss
  3. Gingival recession
  4. Tooth decalcification
  5. Incomplete bite correction
  6. More orthodontics due to maturations
  7. Open conatcts
  8. Surgery
  9. Change in treatment plan

I have been offered referal to a specialist and I choose to have treatment rendered by Dr. Siraj Baig and I am the financially responsible person for this account. I have understood and agree to these terms and that alternatives have been properly explained to me.





Dr. Siraj R. Baig

D.D.S.