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Agreement

Welcome to Miami Bay Oral Health
Here you will be part of a family of Oral Health Care Professionals.
Know that your friends and family are always welcome.
As a special thank you for coming to all of your appointments, you will receive complementary whitening after your orthodontic treatment is complete!
Appointments will be made on a “First Come First Serve” basis. Monday through Friday from 9:00am to 6:00 pm -Saturday from 8:00am to 12:00pm.

1. TYPE OF BRACES: All down payments will include Installation of braces + x-ray + photos + polish cleaning.
A. Regular Metal Braces: Down payment is $200 with monthly payments of $50 (The cost of the bracket replacement is $5)
B. Regular Porcelain (clear) braces, Self-Ligating Metal Braces: Down payment is $300 with monthly payments of $60 (The cost of the bracket replacement is $10)

During the FIRST MONTH of installation we will provide you a FREE REBOND bracket if necessary. Since we don’t work with change ($), we recommend you to bring exact change or pay with card. If your bracket comes off within 48 hours after being installed at your last office visit, we will not charge you for the rebond. However, if it comes off and you’re unable to come in the office that same day you must give us a call to let us know when your bracket fell. We will put it in our system and you will not be charged at your next visit.
2. Missed appointments: A charge of $50 will incur and will be added to your next monthly payment when 3 consecutive appointments are missed. This is the cost for the reactivation of the braces.
3. The costs that have been discussed above refer exclusively to the Orthodontic procedures. The need of any restorative or surgical treatments will be at an extra cost. Not following proper care of braces and failing to keep proper oral hygiene will increase chances of decay and other oral diseases that will have to be treated and it will cost more to treat. So we advise you to get one cleaning every time you come for your monthly follow up appointment. You can choose from regular cleaning $40, deep cleaning $300 or bracket cleaning $15.
4. Your teeth will not align properly if you miss appointments. Patients must follow the instructions of care as well as attending follow up appointments
preferably 21 days (3 weeks) after the last appointment. This is the patient’s responsibility.
5. Patients will receive a free whitening at the end of treatment only if the patient has attended all of the follow up appointments until the completion of treatment.
6. You will not be penalized for terminating treatment but if you would like to remove the braces before treatment is complete and without authorization of the dentist there will be a charge of $150 for removal of the braces. Please be advised that your teeth will move back to their original position and that will be your responsibility.
7. For retainer placement (after finished ortho treatment), there will be a charge of $150.00 for each one. Be advised,
patients will have to come for follow ups the first 6 months after removal of regular braces, and t he patient will pay a monthly fee of $50.
8. If you refer us to your friends you will earn one free monthly payment for each friend recommended by you that starts treatment with us
9. Every time the doctor requires an x-ray to see how your treatment is going you need to pay $25
(usually taken every 6 months).
10. If you already have braces from another treatment and the doctor has evaluated and confirmed that

we can continue the treatment using your same brackets you will have to pay $100 down payment for metal braces, $200 down payment for porcelain braces or self-ligating. You will additionally have to pay for the Panoramic x-ray ($25) and any brackets that need to be replaced ($5 for metal, $10 for porcelain/self-ligating). In the case that we will not be able to continue the treatment with your existing brackets, there will be a $50 fee for their removal in addition to the payment for installing the new braces. 11. In case the patient does not like the color of the rubber bands placed the day of installation they will not be charged, however if it’s been more than one day after installation there will be a $10 charge.

12. The treatment will always start with bracketing the upper or lower arch depending on the case, never both at once. We recommend for faster treatment, that the patient come back in 3 weeks otherwise, to come back in 4 weeks for a regular treatment. Every consultation will have to be paid.
13. The price of the monthly payment can be changed anytime and you will get a notice of this change 30 days in advance.

14. The latest appointment time is 5.30pm, if you arrive past 5:45 you will be charged a late fee. The fee is the value of one monthly payment of your treatment. If you cannot be here before 5:30pm during weekdays you are very welcome to come on Saturdays.
15. If you decide not to start the treatment after X-Rays have been taken there will be a fee of $50.00.

16. If elastics bag is lost after it has been given to you there will be a $5 replacement fee.
17. SUCCESS OF TREATMENT: We intend to do everything possible to provide the best result in every case and it is our opinion that the treatment will be beneficial. However, we cannot guarantee that the proposed treatment will be successful or to your complete satisfaction. Due to individual patient differences, there exists a possibility of failure, relapse, or selective retreatment, despite the best care. Much of the success of the treatment depends on the understanding and cooperation of the patient.
18. CERAMIC/METAL BRACKETS:There have been some reported incidents of patients experiencing bracket breakage and/or damage to teeth. If brackets fracture outside of the office, it
may result in sharp edges which might be harmful to the patient. Also, these brackets may cause enamel flaking and/or enamel fracturing on the understanding and cooperation of the patient. REMOVAL OF TEETH: Sometimes teeth must be extracted as part of the orthodontic procedure. This will be based on the dentists’ judgement of the case. Such removal can include but is not limited to third molar teeth (”wisdom teeth”) and will not be done in this clinic but by another general dentist or an oral surgeon as deemed necessary, and is NOT included in the Ortho treatment fee. PAYMENT POLICIES: We have set- up a payment schedule for your convenience. Please keep in mind that your monthly fee must be paid at the day of your maintenance appointments. ACQUAINTANCES: We recommend that acquaintances wait in the reception area. Inside the operatories of the clinic there are harmful equipment and materials and we will not be responsible for any accident if they are inside with the patient.
19 .In the event that a patient requires a specific orthodontic appliance to improve their treatment results, the patient will be informed of the additional costs.

20. PLEASE PRINT AND BRING THEN FILLED OUT ON THE DAY OF YOUR CONSULT !! This is importand to help in the speed up of your initial appointment CLICK HERE
21. INFORMED CONSENT AND TREATMENT AUTHORIZATION
I have read, and understand, the above and have had the opportunity to discuss it with dentist to clarify any areas I do not understand. I authorize Miami bay oral health to provide me an orthodontic treatment. The prescribed treatment was explained to me.
I FURTHER UNDERSTAND THAT, LIKE OTHER HEALING ARTS, THE PRACTICE OF ORTHOD ONTICS IS NOT AN EXACT SCIENCE: THEREFOR, RESULTS CANNOT BE GUARANTEED AND THOUGH EVERY EFFORT WILL BE MADE TO COMPLETE THE TREATMENT WITH THE SAME DENTIST, THAT CANNOT BE GUARANTEED.

Patient/Guardian Signature: __________________________________________________________ Date: _____________________________