...everything you need to know about orthodontics.
Contract for Provision of Orthodontics Treatment
Contract for provision of professional dental treatments signed by Dr. Lombardi Maximiliano Javier (registred in Colegio de Odontologos 2ª circ de la Ciudad de Rosario) on one side and Mr. (a) _________________________ with regards to ORTHODONTICS treatment. RECORD _________________________ who from now on will be named “The patient” had an appointment with Dr. Lombardi Maximiliano Javier who from now on will be named “The doctor” to have an orthodontics examination. After the corresponding studies, the doctor arrived to the following
DIAGNOSIS: _________________________
Therefore it is important to state the following
TREATMENT A.Duration: B.Equipment:_________________________ C.Extractions: _________________________ D.Procedure:_________________________ E.Objectives.- F. Comments:___
COSTS AND PAYMENT:
The orthodontics treatment has a net cost of $__ It will be divided in an initial payment of and the rest in fixed monthly fees of .All visits and the equipment needed during the orthodontics treatment are included in the cost, but the is NO other service included, such as: Cleaning, whitening, resin, extractions, composite resin dental fillings, etc And final retainers and also NOT included. In order to carry on the treatment there are some:
CLAUSES:
First.- The patient is committed to accomplish his responsabilities regarding care of equipment, cooperation, absolute oral hygiene, punctual attendance to appointments, proper use of accesories. Also to be careful no to bite hard meals during the treatment, such as: stale bread, apples, bones and similars, sweets, chewing gum, etc Also not to eat too much sweets, not to suck lemons, not to bite objects like pencils, feathers, etc even not to grab them with the teeth, not to bite his nails.
Second.- The patient must not beak, remove or move the equipment and must not make things to damage his teeth, like bitting pencils, sucking his finger, bitting his lips o bitting his mouth. Bite his nails
Third.- The patient accept that the development and success of the orthodonticstreatment will be influenced by tje biological response of tissues, this influencing on stability factors such as: kind of use of final retainers, presence of third mollars, pernicious habits, teeth memory, tissue reactions, carelessness of oral health and general state, caries, gums, grouwth, functions and changes of his age.
Fourth.- The doctor is committed to proceed with the described treatment, having in mind the highest quality norms and professional efficience stated by the Ethics code governing the Colegio de Odontologos de Rosario, as well as is committed to keep the degree before this institution giving garantee of his preparation and constant updating.
Fifth.- The doctor is committed to keep monthly fees always fixedgiving garantee on no increment during the treatment and even though the patient may be ask to have more visits there will be no extra carges whatsoever. The doctor is also committed not to charge extra fees because of an eventual need of more time to complete the treatment.
Sixth.- The patient accept the cost and procedure of the treatment and to pay the fees on time. The patient also understands that the cost does not include the final retainers of the orthodontics treatment, the loss or breaking of them and also other odontologic procedures unconnected to the orthodontics. . The patient also accept that, in case of having the treatment finished sooner than expected, he will have to pay the monthly fees to complete the net cost of the treatment.
Seventh.- The doctor is committed to place all the orthodontics equipment needed to accomplish the objectives mentioned, as well as to assist the patient properly during the scheduled or extra visits.
Eighth.- The patient will be responsible for any consequences in the case that he had suspended the treatment temporarily, or missed appointments because of any reasons, or interrupted the payment of the monthly fees (more than 2 months' delay)
Ninth.- In the case mentioned in the previous clause and having the patient resumed the treatment, he must pay the pact fees at moment of reinitiating the treatment and new fees to complete the treatment will be set.
Tenth.-The amounts that had not been paid in terms of what was agreed, will generate a 10% interest form the third month on.
Eleventh.- The patient is in his own rights and is conscious about the risks, limitations and possible consequences that an orthodontics treatment implies and he gives his informed consent to undergo the treatment.
Rosario, Argentina
_____________________ _____________________ For the patient gives Dr. Lombardi Maximiliano his consent.
