Signed Date

Date

OoLi Orthodontics Location

OoLi Orthodontist Name

Patient Name

Patient Email

Person Responsible for Patient;s Orthodontic Treatment

Parent / Guardian Name

Parent / Guardian Email

Date to Finish Patient's Orthodontic Treatment with No Additional Fee

This is an agreement between above patient and Won-Woo Park, DMD, MS of OoLi Orthodontics. Patient was dismissed from OoLi Orthodontics due to continued missed appointments and continued lack of cooperation during treatment. OoLi Orthodontics has agreed to reinstate above patient as a patient of record with the above patient agreeing to following conditions.

* Patient agreed to come to all future appointments on time and as scheduled.
* Patient agreed to cooperate fully with all requirements of the treatment plan.
* Patient understands that any future missed appointments or excessive rescheduling of appointments will result in immediate termination of the patient from OoLi Orthodontics.
* Patient understands that patient’s orthodontic treatment should be finished by above “Date to Finish Patient’s Orthodontic Treatment with No Additional Fee”. Any additional time required to finish the patient’s treatment will incur additional fee of $150.00/month.

Sincerely,

W.W. Jonathan Park, DMD, MS