Orthodontic Financial Agreement
All financed treatment plans are 0% APR, with monthly payments due starting the month following the agreement date.
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Patient and Treatment Plan
*Discounts above do not stack with each other, but may combine with large initial payment discounts.
Initial Payment of
0 Monthly Payments of
Lifetime Smile Investment
The fees listed above are valid for 90 days from the date on this form.
I understand the amount due is my responsibility, including any insurance benefit left unpaid by my insurance provider. The amount due is based on the above treatment plan. In the event the treatment plan changes altering the total cost of care, a new financial agreement will be negotiated. I hereby authorize the use of this signature on all my insurance submissions, whether manual or electronic.
Congratulations!
Thank you. Your signed contract has been sent to Stellar Orthodontics. Your treatment coordinator will reach out shortly.
Finalize Contract
The contract below will be delivered to Stellar Orthodontics and your treatment coordinator will reach out to you shortly to schedule a start appointment. No payment is required until the start appointment.