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PAYMENT SCHEDULE & C
ONTRACT
JEFFREY J. THOMPSON, DDS, MS
4851 West 134th Street
Leawood, Kansas 66209
Phone: 913.681.8300
Email: [email protected]
www.JeffThompsonOrtho.com
Patient hereby agrees to pay the unpaid balance of fee____________
to be payed in equal installments of____________.
The first installment being payable on____________.
All subsequent installments paid ____________ as agreed upon.
*
If insurance benefits are denied or revoked, the patient/parent will be responsible for any unpaid balance.
*If account becomes more than 30 days delinquent, a $15 fee will be assessed per month.
*Accounts that become 60 days past due will be placed on non-progressive status, where only maintenance and emergency
appointments will be scheduled.
I hereby certify that I have read and agree with the foregoing statement.
Signature of patient or parent, if patient is a minor. Date
We only offer payment schedules as a contracted arrangement with payments spread over the length of your anticipated
active treatment time.
Note:This agreement is submitted in good faith to comply with the disclosure requirement, Law 12CFRZZ6 Regulation Z,
truth in Lending, showing no interest or finance charge is being made. We thank you for your cooperation.
Patient/Parent Name________________________________________________________________________________
Address__________________________________________________________________________________________
City____________________________________________________________State_____________Zip______________
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_________