Patient Name:

Parent or Guardian:

Guarantor Address:

Creditor:

Creditor Address:
OoLi Orthodontics - Tempe
7517 S. McClintock Dr. Suite #101
Tempe, AZ 85283

OoLi Orthodontics - Phoenix
6843 N. 8th Ave.
Phoenix, AZ 85013

Total Professional Fee for Orthodontic Treatment:
$
Estimated Insurance Benefit:
$
Down Payment:
$
Estimated Patient Portion (Total Amount Financed):
$

The total professional fee for orthodontic treatment for the patient noted above is:
$
The total discount given is: 
$
The total insurance coverage is:
$
If for any reason your insurance company does not pay the estimated insurance amount, it becomes your financial obligation to OoLi Orthodontics.
The down payment of:
$ (included in the fee), is to be paid on: The balance of the fee is to be paid monthly in following manner:
$ for months.
The first payment is due on: with expected payment completion by: The monthly payments are due on the FIRST OF EVERY MONTH; payments are due monthly regardless of scheduled appointments. The amount financed is payable to OoLi Orthodontics – AZ TEMPE, P.C. or OoLi Orthodontics-AZ, PHX, P.C. at above office address.

• I accept this financial arrangement as the means by which I will pay for the orthodontic treatment of the patient who is named above, and realize that there may be extra charges if there is excessive loose or broken appliances, poor cooperation, or if the treatment time is extended due to uncooperative behavior of the patients. If orthodontic appliances are on 3 months after the projected treatment time due to patient’s negligence, a monthly charge of $175.00 will be billed until the appliances are removed. The above fee includes estimated time of active orthodontic treatment provided at consultation and one year of retention follow-up.
• I am aware of the fact that the above fee does not include any other treatment that may be done by any other practice outside of this practice (e.g. routine cleaning and check-up, extractions, periodontal surgery, etc.).
• If treatment is discontinued at this practice for any reason, there will be an adjustment on the total fee charged, based on the amount of treatment completed. The pro-rated treatment fee is based on usual and customary charges of ¼ down and the balance over treatment time.
• Above contract is subject to change due to insurance coverage, missed appointments and patient cooperation. If at any given time legal documents and or photographs are requested for professional services there will be an additional charge of $300.00 for duplication of records. Patients are subject to missed appointment fees, if we are not notified within 24 hours prior to scheduled appointment time.
• Late charge of $35.00 will be applied to your account after 10 days past due date.
• No show charge of $35.00 will be applied to your account unless our office is notified 24 hours in advance.
• Declined credit card fee $35.00 will be applied.
• Excessive broken bracket fee $35.00 will be applied after 4 broken brackets during treatment.

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INSURANCE

Patients who carry any form of orthodontic insurance should know that OoLi Orthodontics is not an agent of, nor is it associated with, any dental insurance company. At the present time, as a courtesy to our patients, OoLi Orthodontics is happy to provide the service of completing, submitting and receiving payments from your insurance company. It is important that you understand that any pre-estimate, either determined by OoLi Orthodontics or your insurance company is not a guarantee of payment. The insurance payment received is determined by your eligibility at the time of treatment, deductibles, yearly maximum, family maximum and any other of the many criteria your insurance company uses to determine benefits. OoLi Orthodontics cannot guarantee payment or be held responsible for multiple inquiries or requests by your insurance company. The ultimate responsibility of determining and understanding the details, restrictions and limitations of your insurance is yours. All fees for your treatment are your responsibility, not the responsibility of your insurance company. OoLi Orthodontics will make all reasonable efforts to help communicate with your carrier and do the best to obtain your maximum benefit for your treatment. However, OoLi Orthodontics cannot assume responsibility for your insurance company or their refusal to pay claims.

I agree to assume any and all financial responsibilities for orthodontic services not covered by my insurance company. In addition I understand that should my account be sent to the collection agency, additional 50% of the delinquent amount will be added to the total amount due. I hereby affix my signature as acknowledgement and agreement.

Guarantor Name: