
                        
                            Financial Calculator (v5) - Rapid City Braces
                            
                        

        
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                                    Patient Info
Name
                            
                            
                                                    
                                                    First
                                                
                            
                            
                                                    
                                                    Last
                                                
                            
                        
Today's Date
                            
                            MM slash DD slash YYYY
                        
                        
Credit Rating
Treatment Type
Treatment Amount
							
						
Estimated Months in Treatment
Discounts
Discount #1 - Type
Discount #1 - Amount
Discount #2 - Type
Discount #2 - Amount
Discount #3 - Type
Discount #3 - Amount
Fee After Discount
Current Estimated Cost
Is the Patient Paying in Full?
			
					
					Yes
			
			
					
					No
			
Paid in Full Discount Amount
Fee After PIF Discount
Insurance
Does the Patient Have Insurance?
			
					
					Yes
			
			
					
					No
			
Less Estimated Insurance
Insurance Provider 
Initial Payment
Payment Frequency
Does the Patient Have Additional Insurance?
			
					
					Yes
			
			
					
					No
			
Less Additional Estimated Insurance
Additional Insurance Provider 
Additional Insurance Initial Payment
Additional Insurance Payment Frequency
Estimated Cost
Estimated Responsible Party Portion
Estimated Responsible Party Portion (PIF)
                    
                    
                          
                    
                
                
                    
                        Office Payment Options
To offer our patients the most flexibility, we offer multiple options for payment. Payment arrangements will be made with a down payment and automatic monthly payments with no interest.
Option #1
You'll make one down payment of $800 and monthly installments (automatically deducted) for 22 months.
Option #2
You'll make one down payment of $500 and monthly installments (automatically deducted) for 24 months.
Option #3
You'll make one down payment of $177 and monthly installments (automatically deducted) for 26 months.
                    
                    
                          
                    
                
                
                    
                        Down Payment & Payment Options
Down Payment Amount
Final Responsible Party Portion
Final Responsible Party Portion (PIF)
Number of Months
Estimated Monthly Payment
EPP
			
					
					Yes
			
			
					
					No
			
Number of Additional Months
Estimated Monthly Payment (Extended Payment Plan)
                    
                    
                          
                    
                
                
                    
                        Unpaid Balance
Unpaid Balance
Total cost minus the down payment.
Unpaid Balance (Extended Payment Plan)
Total cost minus the down payment, for an extended payment plan.
How Will the Patient Pay the Down Payment?
First Payment Due
                            
                            MM slash DD slash YYYY
                        
                        
Notes for Treatment Coordinator
Signature

Why Choose Us?

Discover what makes Rapid City Orthodontics different than other orthodontic practices and what that means for your smile.

Why Rapid City Orthodontics?

Meet Dr. Page Hudson

Dr. Hudson takes a personalized approach to every smile, combining his high technical skill with a warm and comforting demeanor to help you discover the best version of your smile.

Before moving to the Black Hills, Dr. Hudson owned the largest orthodontic practice in Ventura County, California!