This treatment fee covers all orthodontic appliances necessary for the recommended treatment, routine adjustments during the course of treatment, removal of the braces, placement of retainers, and two years of retainer checks. Broken or lost retainers and alterations to the treatment plan by patient request may be subject to additional fees. The number of financed monthly payments has been established as courtesy and does not correspond to the length of orthodontic treatment.
**We are pleased to assist you with predetermining your insurance benefits and submitting claims to your insurance company on your behalf. If your insurance benefits terminate, or if any portion of the anticipated benefits are not paid by your insurance, all remaining charges will be applied directly to the responsible party.
a) I agree to the above financial contract.
b) I give authorization to Soleil Orthodontics to bill my insurance for services provided.
c) I agree to assume responsibility of all treatment charges outlined above, including any portion of anticipated insurance payments not paid directly to Soleil Orthodontics due to misdirection of funds or loss of insurance coverage.