Date
MM slash DD slash YYYY
OoLi Orthodontics Location
Orthodontist Name
This field is hidden when viewing the form
Orthodontist Name
Prefix First Last
This field is hidden when viewing the form
Orthodontist Email
Patient Name
Prefix First Last
Address
Street Address Address Line 2 City State ZIP Code
Patient Email
Patient Phone
Financial Promissory Note Singer(Required)
- Patient
- Parent / Guardian
Parent / Guardian Name
Prefix First Last
Parent / Guardian Email
Parent / Guardian Phone
Financial Obligation Due Date
Month
Day
Year
Financial Obligation Past Due Amount
Financial Obligation Total Balance
Body of Letter
This letter is to inform you of your past due balance. Your balance is now over 60 days past due. Please see your financial obligation to date, which is noted above. Our office provides quality orthodontic care to our patients for a reasonable fee and with a convenient schedule. This service cannot be provided if we continue to treat patients who neglect to keep their accounts current. According to our record we have not received either a reply to our previous past due notice letter or a payment to bring your account to date. So that no further action on our part will be necessary, we shall expect a remittance by return mail or the courtesy of a reply to our letter as to why payment is being withheld. Thank you for your prompt attention to this matter. Sincerely, W.W. Jonathan Park, DMD, MS

Date
MM slash DD slash YYYY
OoLi Orthodontics Location
Orthodontist Name
This field is hidden when viewing the form
Orthodontist Name
Prefix First Last
This field is hidden when viewing the form
Orthodontist Email
Patient Name
Prefix First Last
Address
Street Address Address Line 2 City State ZIP Code
Patient Email
Patient Phone
Financial Promissory Note Singer(Required)
- Patient
- Parent / Guardian
Parent / Guardian Name
Prefix First Last
Parent / Guardian Email
Parent / Guardian Phone
Financial Obligation Due Date
Month
Day
Year
Financial Obligation Past Due Amount
Financial Obligation Total Balance
Body of Letter
This letter is to inform you of your past due balance. Your balance is now over 60 days past due. Please see your financial obligation to date, which is noted above. Our office provides quality orthodontic care to our patients for a reasonable fee and with a convenient schedule. This service cannot be provided if we continue to treat patients who neglect to keep their accounts current. According to our record we have not received either a reply to our previous past due notice letter or a payment to bring your account to date. So that no further action on our part will be necessary, we shall expect a remittance by return mail or the courtesy of a reply to our letter as to why payment is being withheld. Thank you for your prompt attention to this matter. Sincerely, W.W. Jonathan Park, DMD, MS