Here’s a good idea from Dr. David Sarver in Birmingham, Alabama. Fortunately he was willing to share it with us. Dr. Sarver developed a check list that is presented to his patients at the time of case presentation. This list is covered during the presentation and a signed copy is retained in the patient’s record. This does a lot to avoid the “you never told me that” situation that can arise during treatment. While we all understand that not everything that is explained, especially during the initial phases of treatment, is retained by the patient/parent at least this list helps to ensure that all these steps are specifically covered and with its signature it indicates that at least at that point in time the patient/parent understood.

You may want to modify this for your particular situation, but it is a good starting point.

en Francais

What does fee include?

Phase I: All active treatment, all future x-rays during that time, 4 month leeway period, and first retainer.

Full Treatment/Phase II: All active treatment, all future x-rays during that time, 4 month leeway period, first retainers, and one full year of retention visits.

Surgical Treatment: All active treatment, all future x-rays during that time, surgery wires, splint, video imaging, 4 month leeway period, first retainer, and yearly follow-ups.

Transfer Patients: All active treatment, plus a 4 month leeway period, first retainer and one full year retention visits.

Limited Treatment: All active treatment, and x-rays during that time.

Splint Treatment: Covers splint and follow-up visits.

All about payments:

1. Down Payments are due the day of the initial bonding or when the impression for the appliance is taken.

2. Monthly Payments: are due by the 15th of the month.

3. Payment Book: you will receive about 1-2 weeks after the treatment begins. Statements will be sent only when the account becomes 30 days past due.

4. Transfers Out: Pay up through the active treatment in our office, payment will stop here and balance is forwarded to office in the transferring city. If account was paid in full, we will calculate transfer balance.

5. Debonds: final payment and finish date do not always coincide. Payments must be made according to the payment schedule set up with the responsible party.

6. Divorce situations: The person who is responsible for the account needs to sign the T&L an the initial bonding date, or prior to that appointment. Patient information will be revealed only to the custodial parent.

7. Insurance: We will provide you with the necessary information to file charges with insurance.

Additional Charges During Treatment:

1. Lost or broken retainer: payment is due at the time of impression.

2. Lack of Cooperation: if treatment takes longer than the estimated treatment time due to broken appointments, non-compliance with headgear, appliances and rubber bands, monthly charges will be extended until treatment is completed.

3. FEE DOES NOT COVER: services provided by other dental professionals.

4. REPLACEMENT CHARGES FOR FUNCTIONAL APPLIANCE $____________.

5. CLEANINGS: Schedule with your dentist every 6 months.

6. APPOINTMENTS: Only 15 minute appointment will be scheduled after school. If patient has anything loose, appointments are scheduled in the morning or early afternoon due to the time required for these problems.

I have had the above explained to me to my satisfaction:

signed:__________________________________ date__________________