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  • Financial Agreement For Implants

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    Adriana uribe
    83 views2 pages
    This financial agreement outlines a payment plan for dental implant treatment. The patient will make three scheduled payments - the first for implant placement, the second for impressions, and the third for crown placement. Additional potential payments are listed for bone graft, membrane, and extractions. The responsible party signs agreeing to the payment arrangement and treatment fee.

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    Financial Agreement for Implants

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    This financial agreement outlines a payment plan for dental implant treatment. The patient will make three scheduled payments - the first for implant placement, the second for impressions, and the third for crown placement. Additional potential payments are listed for bone graft, membrane, and extractions. The responsible party signs agreeing to the payment arrangement and treatment fee.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    83 views2 pages

    Financial Agreement For Implants

    Uploaded by

    Adriana uribe
    This financial agreement outlines a payment plan for dental implant treatment. The patient will make three scheduled payments - the first for implant placement, the second for impressions, and the third for crown placement. Additional potential payments are listed for bone graft, membrane, and extractions. The responsible party signs agreeing to the payment arrangement and treatment fee.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    DENTAL EXCELLENCE

    Dr. Adriana Uribe


    BLVD SANCHEZ TABOADA 1250-B INT 102
    ZONA RIO TIJUANA B.C. ZIP CODE 22010
    TEL USA:(619)-407-77-71
    P. O. BOX 530176 SAN DIEGO CA. ZIP CODE 92153

    Financial Agreement for Implants


    DATE: ________________________
    PATIENT NAME: _______________________________________________________.
    RESPONSIBLE PARTY: _________________________________________________.
    Dr. Name: _____________________________________________________________.
    Implant Brand: __________________________________________________________.

    PAYMENT ARRANGEMENT

    Treatment Fee (Complete rehabilitation) ………………….. $_______________.

    1st Payment (Implant placement) ………………….……….. $____________ on:


    _____________.

    2nd Payment (Impressions for the crown) ………………… $____________ on:


    _____________.

    3rd Payment (Final Payment, the crown placement day): .. $____________ on:

    _____________.

    Extra Payments (needed for complete restoration).

    Bone Graft: $ _______________ on _______________.


    Membrane: $ _______________ on _______________.
    Extraction: $ _______________ on _______________.

    Additional Payments (needed for complete restoration).


    _________________________________________$ _______________ on
    _______________.
    _________________________________________$ _______________ on
    _______________.
    _________________________________________$ _______________ on
    _______________.
    DENTAL EXCELLENCE
    Dr. Adriana Uribe
    BLVD SANCHEZ TABOADA 1250-B INT 102
    ZONA RIO TIJUANA B.C. ZIP CODE 22010
    TEL USA:(619)-407-77-71
    P. O. BOX 530176 SAN DIEGO CA. ZIP CODE 92153

    _________________________________________$ _______________ on
    _______________.

    _____________________________________________ _______________
    ________________
    Signature of Responsible Party Date Dr. Signed.

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