Avenue Dental Center Steven C. Pinegar, D.D.S. 1021 North University Avenue Provo, UT 84604 (801) 373-8221 For simple and fast financing at a local credit union click here. Patient Name: _______________________________ Date:  _________________ The investment for dental treatment is Less estimated insurance* Patient Responsibility $________________ $________________ $________________ Dental treatment is an excellent investment in an individual's medical and psychological well being.  Financial considerations should not be an obstacle to obtaining this important health service.  Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the following payment options. PAYMENT OPTIONS Flexible Monthly Payment Option (Dental Fee Plan) No initial payment Payment plans up to 60 months with monthly payments as low as $________ which includes a low fixed rate Additional payment plans are available Prepayments can be made anytime without penalty Fast, confidential service by phone, 1-800-204-3332, or on-line at DFP's secure web site, www.dentalfeeplan.com.  Good credit standing is required. Interest Fee Option (Dental Fee Plan) Multiple Interest Free Terms available Minimums as low as $300 No interest charges if paid within the specified time period Retroactive finance charges of 19.99% applies if treatment fee is not paid during the Interest Free period. Please note the required minimum monthly payment will be based on the terms of your loan. Fast, confidential service by phone, 1-800-204-3332, or on-line at DFP's secure web site, www.dentalfeeplan.com. Payment in Full A bookkeeping courtesy of 5% or $____________ is given for direct payment in full by cash or check at start of treatment, resulting in a one-time payment of $___________. Office Payment Plan It is anticipated that treatment will take _________ visits.  For your convenience, the treatment fee may be paid according to the treatment plan with _________ monthly payments of $___________.  The first sixty (60) days are interest free. Care Credit Credit card for health care costs Interest free payment plans up to 12 months with payments as low as $________ Interest retroactive at _______% if a payment is missed or not paid in full within the interest free period Applications available in the office We Accept Visa, MasterCard, Discover and American Express *If for any reason the estimated amount is not paid by your insurance company, it becomes your obligation.