Treatment Start Preparation Sheet

1 - Patient Name *

First Name

Last Name

2 - Name of primary person responsible for account *

First Name

Last Name

3a - Will the account be split with another payee? *

Will someone other than the person named above be paying for a portion of the fee and require a split contract? (This refers to you needing a completely separate contract that reflects a portion of the fee - example Parent A pays 50% of the total fee and parent B pays 50%, each parent requiring their own agreement separate from the other)

Yes

No (Skip to Question 4)

3b - Name of second person responsible for account (if applicable)

First Name

Last Name

4a - Review of Agreement - Correct Treatment Selection?

Please review the financial agreement provided by this office. Do all of the details match the treatment you have chosen? Ie: Type of braces (Traditional, Clear, Invisalign, Lingual), Accelerated Treatment option selected if you prefer.

Yes

No (if no, please outline any required changes in the comment box below)

4b - Review of Agreement - Financial Arrangements

Do the financial agreements set out in the agreement still work for your preferences? Please recall: your insurance company may dictate a different repayment schedule that you have selected here - be sure to consult your insurance guidelines or discuss with your provider.

Yes

No (if no please outline any required changes in the comment box below)

5a - Method of payment of the initial fee

Please note that we are unable to accept cash payments

Visa

Mastercard

Debit (be sure to check your daily or per-transaction limits with your bank)

Certified cheque or money order (payable to Marguerite Duncan Professional Corp)

5b - Method of payment of monthly fees

(if applicable - not applicable if you have elected to pay in full at the start of treatment)

Visa

Mastercard

Automatic Bank Withdrawal (VOID cheque required)

5c - Preferred monthly payment date (if applicable)

If you have selected a monthly payment plan, Simply Orthodontics will set up your monthly automatic withdrawals on either the 5th or the 20th of each month. Please indicate your preferences:

I prefer to make my payments on the 5th of each month

I prefer to make my payments on the 20th of each month

6 - I am aware that a valid government issued ID is required for all responsible parties - I/We will bring this to the next appointment *

I am aware and will bring my ID