financialOrthodontic treatment is an excellent investment in the overall dental, medical, and psychological well-being of children and adults. Financial considerations should not be an obstacle to obtaining this important health service. Being sensitive to the fact that different people have different needs in fulfilling their financial obligations, we are providing the following payment options:

Patient Name                                                                                        Date 10/19/2011

Records $
Orthodontic treatment
Retention $ -
Fee for treatment * $
Insurance Discount $
Expected Insurance ** $ -
Patient Responsibility $

* Treatment Fee includes Comprehensive Exam; Diagnostic Evaluation; All Appointments; Retainers Upon Completion; Retention Visits For One Year

** If for any reason the estimated amount is not paid by your insurance company, it becomes your responsibility

Option A: Payment-in-full

A bookkeeping credit of— 3.00% is for payment-in-full at the start of treatment
by cash or check resulting in a one-time payment of — $ 4,559.00 (no credit cards)

Option B: Office Payment Plan

An initial payment of — $ 2,825.00 is due when separators are placed or an impression for an
appliance is taken. The balance is paid in— 15 consecutive payments of— $ 125.00

Option C: Office Payment Plan - Spreading the initial payment

The initial payment is paid in 3 consecutive monthly payments of $ 941.67
the first of which is due when separators are placed or an impression for an appliance is taken.
The balance is paid in — 15 consecutive monthly payments of $ 125.00

Option D: Lending Club Patient Solutions

Lending Club
It is Lending Club Patient Solutions. Their website is www.lendingclub.com/dental and phone number is (800) 630-1663.