We are so excited to be starting orthodontic treatment for you!   So we may be prepared for your appointment, kindly take a few moments to confirm your financial preferences using the form below.  No card numbers or similar information is required at this time - please bring that documentation along with you to your next appointment. 

Insurance Reminder: If you are fortunate enough to have orthodontic insurance coverage, our office will provide you with the forms you will require for submission of your claim, as well as instructions on how to access and print your monthly receipts at your convenience using our secure online patient login. You will need to submit your forms and receipts to get reimbursed directly from your insurance carrier. 

Thank you for choosing Simply Orthodontics!

1 - Patient Name *
1 - Patient Name
2 - Name of primary person responsible for account *
2 - Name of primary person responsible for account
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)
3b - Name of second person responsible for account (if applicable)
3b - Name of second person responsible for account (if applicable)
Please indicate how the contract is going to be split with this person, and please inform this person that we will be contacting them to learn their payment preferences and prepare their separate paperwork.
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.
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.
If you selected NO above, please indicate any required changes here. Examples of changes you may wish to request include changing the type of braces you prefer, changing the payment schedule (initial payment increase or decrease etc), adding or deleting the option to include Accelerated Treatment. Please be descriptive and we will contact you to ensure the arrangements meet your needs.
5a - Method of payment of the initial fee
Please note that we are unable to accept cash payments
5b - Method of payment of monthly fees
(if applicable - not applicable if you have elected to pay in full at the start of treatment)
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:
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 *