Internal Financial Estimator -

Enter treatment details first. The patient-facing investment summary appears after calculation.

Patient Name *

Treatment Type * Estimated Treatment Length * Base Treatment Investment $ *

Records / Scan / Impression Braces Removal Attachment Removal Appliance Removal Additional Service Notes

Hawley retainers, specialty retainers, replacement retainers, or additional appliances may have an additional fee.

Promotional / Courtesy Type Promotional / Courtesy Savings $ Estimated Insurance Benefit $ Notes

Parent / Patient Email Required Selected Payment Method Discussed and Agreed Patient is starting treatment today / agreement accepted

Select only the payment option(s) discussed with the patient. You may select one, two, or all three.

Include Cash / Card Option Include In-House Option Include Third-Party Financing Option Include Custom Payment Arrangement

Patient / Responsible Party Signature (optional — leave blank if sending after the patient has left)

Financial Investment Estimator