The Dental Financial Agreement Template – Canada is offered in multiple formats, including PDF, Word, and Google Docs. Each version is customizable and ready for printing, ensuring that you can easily adapt it to your requirements.
Dental Financial Agreement Template – Canada Editable – PrintableSample
1. Parties Involved 2. Purpose of the Agreement 3. Services Covered 4. Payment Terms 5. Estimated Costs 6. Insurance Information 7. Late Payment Policy 8. Cancellation Policy 9. Dispute Resolution 10. Acknowledgment of Agreement
PDF
WORD
Examples
[Patient’s Name]
[Patient’s ID]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Dental Practice Name]
[Dental Practice ID]
[Practice Address]
[Practice Phone]
[Practice Email]
This Dental Financial Agreement (“Agreement”) outlines the financial responsibilities and payment terms between [Patient’s Name] and [Dental Practice Name], effective from [Start Date].
The Dental Practice agrees to provide dental services as detailed in the treatment plan presented to the Patient. The Patient acknowledges understanding of the proposed treatments.
The Patient agrees to pay fees of [amount] for the services rendered. Payment is due at the time of service unless alternative arrangements have been made.
The Patient must provide accurate information regarding insurance coverage. The Dental Practice will assist in filing claims but is not responsible for any unpaid amounts arising from denial of claims.
Payment may be made via cash, credit card, or financing plans offered by the Dental Practice. Details of financing plans will be provided upon request.
In the event of late payment, the Patient acknowledges and agrees to a late fee of [percentage]% of the unpaid balance, accruing monthly until the balance is settled.
Should the Patient wish to cancel or reschedule an appointment, a notice of [Notice Period] is required to avoid cancellation fees.
This Agreement shall be governed by the laws of Canada.
[Patient’s Signature]
[Patient’s Name]
[Dental Practice’s Signature]
[Dental Practice’s Name]
[Patient’s Name]
[Patient’s ID]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Dental Practice Name]
[Dental Practice ID]
[Practice Address]
[Practice Phone]
[Practice Email]
This Dental Financial Agreement (“Agreement”) sets forth the terms and obligations regarding financial matters between [Patient’s Name] and [Dental Practice Name], effective from [Start Date].
The Dental Practice will provide the Patient with a detailed estimate of costs prior to any procedures, ensuring clarity on services received and associated fees.
The Patient agrees to make payments as outlined in the fee schedule. Payments must be made in full or in agreed installments prior to receiving services.
The Patient is responsible for all charges not covered by insurance. The Dental Practice will bill direct insurance when applicable, but full responsibility for payment remains with the Patient.
In case of financial hardship, the Patient may discuss payment plan options that are offered by the Dental Practice to accommodate ongoing care.
If the Patient fails to make payments as agreed, the Dental Practice reserves the right to refer the account to collections and the Patient may incur additional legal fees.
The Patient is required to provide accurate personal and insurance information to the Dental Practice, and to inform them of any changes to this information promptly.
This Agreement shall be governed by the applicable laws of Canada.
[Patient’s Signature]
[Patient’s Name]
[Dental Practice’s Signature]
[Dental Practice’s Name]
Printable
