Free Dental Office Payment Plan Template
Dental Office Payment Plan
This Dental Office Payment Plan ("Agreement") is made between [YOUR COMPANY NAME] and Barry Morar, hereinafter referred to as the "Patient." The following outlines the payment terms for services rendered by [YOUR COMPANY NAME]. By signing this agreement, the Patient agrees to the terms set forth below.
1. Services Provided
[YOUR COMPANY NAME] has provided or will provide the following services to the Patient:
-
Initial Consultation: $150.00
-
Cleaning & Examination: $200.00
-
Fillings (2 cavities): $500.00
-
Root Canal Treatment (Tooth #12): $1,200.00
-
Crown Placement: $1,000.00
Total Services Cost: $3,050.00
2. Payment Plan Details
The total cost of services is $3,050.00. The Patient agrees to pay this amount through the following payment plan:
-
Deposit Due at Time of Service: $500.00
-
Remaining Balance: $2,550.00
The remaining balance will be divided into 6 equal monthly payments of $425.00 each. Payments are due on the 1st day of each month starting from June 05, 2060.
3. Payment Schedule
|
Payment Due Date |
Payment Amount |
Remaining Balance |
|---|---|---|
|
June 05, 2060 |
$425.00 |
$2,125.00 |
|
July 05, 2060 |
$425.00 |
$1,700.00 |
|
August 05, 2060 |
$425.00 |
$1,275.00 |
|
September 05, 2060 |
$425.00 |
$850.00 |
|
October 05, 2060 |
$425.00 |
$425.00 |
|
November 05, 2060 |
$425.00 |
$0.00 |
4. Late Payment and Fees
If a payment is not made within 5 days of the due date, a late fee of $25.00 will be applied. After 30 days of non-payment, the balance may be sent to collections, and further treatment will be withheld until payment is received.
5. Changes to Payment Plan
If the Patient wishes to change the terms of this payment plan, they must request approval from [YOUR COMPANY NAME] in writing. Any changes to the plan must be mutually agreed upon before implementation.
6. Payment Methods Accepted
[YOUR COMPANY NAME] accepts the following forms of payment:
-
Credit/Debit Card
-
Personal Checks
-
Cash
-
Health Savings Account (HSA)
-
Flexible Spending Account (FSA)
7. Authorization
By signing below, the Patient agrees to adhere to the terms and conditions outlined in this Payment Plan Agreement. The Patient also authorizes [YOUR COMPANY NAME] to process the payments according to the schedule provided.
Barry Morar
Date: May 25, 2060
[YOUR NAME]
Date: May 25, 2060
