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American Dental Cambridge
American Dental Quincy
Sign In
My Account
Invisalign Payment
Select your office
Sahara Dental Center
American Dental Malden
American Dental Watertown
American Dental Cambridge
American Dental Quincy
New Patient Form
Patient Information:
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
SSN
Cell Phone
*
(###)
###
####
Email Address
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Invisalign Case
Case Type
*
Invisalign Full (Comprehensive Treatment) with Warranty.
Invisalign Teen
Invisalign lite
Invisalign Express (Please Specify):
Invisalign GO
Number of aligners
*
Number of Months
*
Warranty: Only for invisalign FULL treatment.
Start date
MM
DD
YYYY
End date
MM
DD
YYYY
Financial Section
Total Treatment Cost
$
Insurance Coverage
Please select
Yes
No
If yes please indicate the amount and limitations:
Payment
$
Full Payment (After Applying 5% Discount)
$
Payment Plan with Zero Interest
Down Payment
$
Patient records and Invisalign Video Payment Credit
$
Monthly Payment (per month)
$
Number Of Months
Payment Plan Methods
Credit Card Over the phone (Payment will be made over the phone.)
Online Payment Via Website (Payment will be made via using the Invisalign Payment website: www.invisalignpayment.com)
Mailing a check to the office (A check will be mailed to the office location: 364 Harvard St. # 1C Brookline, MA 02446)
Invisalign Package
The Invisalign Package and Benefits:
Free Philips Zoom Whitening (In-Office)
Free Dental Retainer
HomeCare Whitening Kit (Zoom)
Free Periodic Check Ups and Teeth Cleaning during the treatment Time (If there is no insurance or the insurance does not cover this service).
Oral health care kit, every 3 months for FREE. It includes a tooth brush, tooth paste, dental floss and mouthwash.
Possible treatment Warranty. Invisalign Full (Comprehensive) Treatment is covered by a ( FIVE YEAR Warranty). Any extra Aligners to align teeth needed within 5 years from the treatment start date should be covered and FREE of Charge 100%.
Name of The Dentist
*
Any Referral?
*
Please select
Yes
No
Name and number of the referred Person (if any)
To the best of my knowledge, the information given today is correct and it is my responsibility to inform this office of any changes in my medical stats. I authorize the dental staff to perform the necessary dental services that I may need. I understand that payment is due in full at time of treatment unless prior arrangements have been approved.
initials
Patient's Name
*
First Name
Last Name
Today's Date
*
MM
DD
YYYY
Financial Policy
Thank you for choosing American Dental Consultants for your treatment. Our goal is to provide you with the best possible dental care and help you to maintain your teeth for a lifetime. Out office manager will be available to discuss your insurance, financial or care credit needs, if necessary. We accept personal checks, as well as MasterCard and Visa for your convenience. As a matter of courtesy to our patients, we will bill your insurance carrier. We will submit the original insurance claim and follow-up claim if necessary; however, you are responsible for the entire bill. If your insurance carrier does not remit payment within 60 days from the time the claim has been submitted, the balance will due in full from and you should contact your insurance carrier to find out why payment has been has been delayed. If there are any payments made our your insurance carrier in excess of the estimated balance, we will refund the credit amount owed to you, unless you ask us to retain the balance for your immediate dental treatment. In case of insurance does not agree to pay the indicated amount to cover the part of the treatment as mentioned in the patient insurance eligibility, patient could be responsible for this aforementioned part. The fee listed is applicable if treatment is commenced within 60 days. I completely understand the financial policy as stated above and as such. I agree that the total cost of the treatment is my responsibility.
*
initials
Thank you for applying with us!
