If the scheduled payment is not received within 15 days of its due date, a late fee of $25.00 will be assessed each month until the account is brought current. Treatment will be suspended on patients whose accounts are more than 90 days past due until the account is brought current. During treatment suspension, we will monitor oral hygiene and attend to orthodontic emergencies only; however, treatment progress will not continue and treatment length may increase. Because unsupervised orthodontic care may result in cavities, gum disease, or other serious problems, prolonged suspension and/or multiple failed appointments will result in patient dismissal. If an account becomes more than 120 days past due, the patient will be dismissed and may be seen on an emergency basis only for 30 days.

I authorize North County Orthodontics to process debit entries to my bank or credit card account. I understand that my information will be saved on file for future transactions on my account. Furthermore I understand that my information with remain in effect until I provide reasonable notification to terminate the authorization.