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THOMPSON, DDS, MS 4851 West 134th Street Leawood, Kansas 66209 Phone: 913.681.8300 Email: info jeffthompsonortho.com www.JeffThompsonOrtho.com Patient/Parent Name Address CityStateZip Re: Orthodontic Records, Diagnostic Evaluation and Consultation Orthodontic treatment Fee Anticipated Insurance Adjustment Anticipated Insurance Payment Ceramic or Gold Brackets iBrace Lab Fee Paid in Full Reduction Less Initial Payment Unpaid Balance of Fee Finance Charge none Patient hereby agrees to pay the unpaid balance of fee to be payed in equal installments of..
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