General Dentistry / Orthodontist

Tel. 541 07 25 Mobile No. 0908-883 3345 55 Greenheights Ave., Greenheights Village, Sucat Paranaque

Patient:______________________________ Age:___ Sex:___ Status:___ Birthday:__________________ Tel no:____________________ Mobile no:____________________ Parent/Guardian:_________________ During orthodontic treatment, patient is to avoid / refrain from eating junk foods,crispy pata,chicharon,chewing on ice & hard candy, cornick,nuts,corn on a cob,gum & other very sweet & sticky candies & chocolates. GOOD ORAL HYGIENE & GOOD & PROPER BRUSHING IS A MUST, to prevent tooth decay/caries & plaque formation. Patient is expected to keep regular check-up & adjustments; must brush teeth before coming to the clinic. Repetitive dislodgement/debonding of brackets will affect treatment & prolong treatment time thus additional payment wil also be. Missed appointments or no adjustment does not mean no payment of monthly due. A 10% surcharge will be added per month if monthly due is not paid on time. Rebonding of dislodged bracket/ recementation of molar band is Php1,000.00. Replacement of lost bracket is Php800.00/pc.; molar band is Php1,000.00/pc.; broken archwire is from Php500.00 up depending on the type of AW. Total cost of fixed orthodontic treatment does not include removable ortho appliance, extraction, fillings, study cast, scaling and debridement of plaque, orthodontic toothbrush & wax. To ease out difficulty of chewing big chunk of meat, it must be sliced into small pieces as well as pizzas and corn must be removed from the cob. Brush very well 3x a day & before coming to the clinic! Estimated length of treatment: Active phase________mos .(non-exo);________ (exo.case); Passive phase__________mos Total cost of treatment: P_____________; Initial Payment Php________ Balance; Php_________; Php_________//_____mos. Postdated ___________ checks:______ pcs. Bank:___________________ Account Number:_________________________________________________________ *If patient cannot make it to the appointed time & date of check-up/adj.,it must be cancelled 1-2 days before so that slot can be give to other patients. *There will be a php600.00 fee for every uncancelled appointment!! *There will be a minimum php600.00 fee for every check-up/adj.beyond the prescribed time of treatment due to the patients repeated absences for some reasons. CONFORME Person responsible to pay for the treatment; Parent/Guardian (Signature) _____________________________________ Address: Contact no:___________________ Mobile no:______________________ Patient (Signature)_________________________ understood & will follow above mentioned instructions Date:____________