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04/02/2025
Proposal Treatment
Dr. John Doe
123 Main St, Anytown, USA
MAURA
123 Main St, Anytown, USA
ID : AF54hh
| Phase | Date Plan | Appt | Provider | Service | TTH | Surf | Fee | Ins | Pat |
| 1 | 04/02/2025 | 04/02/2025 | DJO | Comprehensive ORAL EVALUSA | 16 | $200 | $50 | $20 | |
| Subtotal | $0.00 | $0.00 | $0.00 | ||||||
| Tax | $0.00 |
Insurance Coverage is only an estimation. A guarantor is responsible for all treatment not covered by insurance. The Above prices are valid for 60 days.
Total Proposed
$0.00
Total Completed
$5000
Total Accepted
$5000
Proposed Insurance
$0.00
I have been advised of the treatment recommendation above, I am aware delaying treatment may lead to more extensive and costly treatment. A new exam may be required after 60 days
Patient or Guardian's Signature________________________________________Date
Current Dental Terminology(CDT) © American Dental Association(ADA). All Rights Reserved
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