Auto Pay Down payment: 0.00
Auto Pay Payment: 0.00

885 Pancheri Dr • Idaho Falls, ID 83402 • 208-524-0870

Patient name: Presented by: Date:
Treatment plan


Detailed treatment plan available upon request
If you don't use your insurance benefits, they run out in days
Total fee: $0.00
Possible insurance benefits to be paid: $0.00
Total due after insurance: $0.00
Pay in full
Pay in full with cash, check, debit, or credit card You pay: $0.00
In-office
payments
50% down payment required Down payment required: $0.00
Pay 2 monthly payments to be paid by ____________________ You pay: $0.00/mo.
Pay 3 monthly payments to be paid by ____________________ You pay: $0.00/mo.
Initial payment due at time of scheduling.
Auto Pay
Automatic Payment Withdrawal
10% Flat interest rate
$500 minimum treatment
No credit check
Initial payment due at time of scheduling. Maximum term of 18 months. Late charges will apply. 		Down payment required: $0.00
Financed amount including interest: $0.00
Payments starting at: $0.00/mo.
Term length: 12 months
Loan
Banks or credit unions often offer loans for dental treatment. Ask us for details.
I Choose: (put your initials next to your choice)
    ______ Pay in full with cash or check
    ______ Pay in full with debit or credit card
    ______ Care Credit (pay in full using Care Credit after insurance pays)
    ______ In-office payments
    ______ Auto pay $_____________ per month
    ______ Loan
Notes:

I understand I have chosen the treatment option presented on this form. It is my responsibility to inform doctors and staff of any changes.

I understand that the above estimated fees are based on my treatment plan as listed above. The treatment plan may change, altering the total cost of care.

Insurance figures are estimates only. If your insurance pays less than anticipated, you will be responsible for the difference.

The undersigned agrees to the above terms and authorizes inquiry of credit information. I understand and agree that in the event of non-payment of any amount due, that Park West Dental Care may add interest at the rate of 1.75% per month (21% per annum). I further understand and agree that in the event any unpaid balance is assigned to a third party for collection, that an additional collection fee of 35% of the unpaid balance will be added. Should legal action be required to enforce payment of this contract, the signer(s) hereof agree to pay reasonable attorney's fees and court costs incurred by the need of such action.



Patient (or responsible party) signature Date


Witness Date