Strand contract

                                                                                                                                 770 Cherrington Row
                                                                                                                                                Suite B
                                                                                                                                 Westerville, OH 43081

Strand Orthodontics
                                                                                                                                       (614) 555-0171
                                                                                                                                  strandortho.example



                        ORTHODONTIC TREATMENT AND FINANCIAL AGREEMENT
Patient: Nora E. Adeyemi, date of birth 09/21/2014                             active treatment.
Responsible party: Leah M. Brandvold, 2714 Quillfeather Lane,                  If the patient moves, transfers to another orthodontist or stops treatment,
Westerville, OH 43081                                                          the fee earned is 25% of the total treatment fee at placement, with the rest
Treating orthodontist: Joel Strand, DDS, MS                                    earned evenly over the 22 estimated months. Any amount paid beyond the
Agreement date: February 17, 2026                                              fee earned is refunded within 30 days, and any shortfall is due at the last
1. TREATMENT                                                                   visit. Records are sent to the new orthodontist at no charge.
The practice will provide comprehensive orthodontic treatment with fixed       7. RETAINERS
upper and lower appliances to correct crowding of the upper arch and a         One set of retainers is included. A lost or broken retainer is replaced for
crossbite on the right side. The estimated active treatment time is 22         $175 for each retainer. Teeth move throughout life; the practice cannot
months. This is an estimate and not a promise. Treatment time depends on       promise that they will stay in position if retainers are not worn as
growth, on how the teeth respond, and on how well the patient follows          instructed.
instructions about diet, brushing and elastics.
                                                                               8. CONSENT
2. WHAT THE FEE INCLUDES
                                                                               I have had the treatment plan explained to me, including its limits and
The fee covers the diagnostic records taken at the start, placement of the     risks: sore teeth after adjustments, white marks or decay where brushing
appliances, all regular adjustment visits during active treatment, removal     is poor, shortening of roots, and the need for retainers afterwards. I have
of the appliances, one set of upper and lower retainers, and retainer checks   been given the list of foods to avoid. I agree to the fee and payment
for 12 months after the appliances are removed.                                schedule above.
3. WHAT THE FEE DOES NOT INCLUDE
The fee does not cover care by the family dentist, cleanings, fillings,
                                                                               Leah Brandvold 02/17/2026
extractions or other surgery, or treatment of the jaw joint. It does not       Responsible party
cover a mouthguard for sports. The first two broken brackets are repaired
at no charge; each one after that is $25. An appointment missed without
                                                                               J. Strand 02/17/2026
24 hours' notice may be charged $40.                                           For Strand Orthodontics

4. FEE AND PAYMENT SCHEDULE


  Total treatment fee                                        $5,480.00

  Estimated insurance benefit, Thistledown Dental            -$1,500.00

  Estimated patient portion                                  $3,980.00

  Down payment, due at placement, February 17, 2026          $578.00

  18 monthly payments, March 2026 through August             $189.00 each
  2027


A payment by card on file is run on the due date. A payment more than 10
days late is charged a late fee of $15. If two payments in a row are missed,
the practice may suspend adjustment visits, other than visits to relieve
pain, until the account is current.
5. INSURANCE
The insurance benefit shown is an estimate from the information the plan
gave us on the agreement date. Orthodontic benefits are usually a lifetime
maximum for each covered person and are paid to the practice in
instalments while the patient remains covered. If the plan pays less than
the estimate for any reason, including a change of employer or of plan, the
responsible party owes the difference. If the plan pays more, the
difference is credited to the account.
6. IF TREATMENT TAKES LONGER OR ENDS EARLY
There is no additional fee if active treatment runs up to 6 months past the
estimate. After that, the practice may charge $95 for each further month of