1. Transfer of Care

I acknowledge that I am transferring my orthodontic care from Class 1 to Goldfields Family Dental. I understand that:

• Acceptance of my case is not automatic and is assessed on a case-by-case basis.
• The decision to accept, continue, modify, or decline treatment is at the sole clinical discretion of the treating orthodontist at Goldfields Family Dental.
• My treatment plan may differ from my previous provider’s plan.

2. Treatment Costs & Ongoing Fees

I understand and agree that there will be no ongoing orthodontic treatment costs for transferred cases unless one or more of the following occur:

• Breakage or damage to orthodontic appliances caused by patient fault
• Loss, damage, or replacement of retainers
• Additional treatment, repairs, adjustments, or procedures are required beyond the original transfer scope

Any additional costs will be discussed with me prior to treatment proceeding.

3. Appointment Deposit Policy

I understand and agree that:

• A $150 deposit is required for each appointment booked with the orthodontist.
• The deposit is required at the time of booking to secure the appointment.

Failure to Attend / Late Cancellation:

• If I fail to attend my appointment or cancel with less than 24 hours’ notice, the $150 deposit will be forfeited.

Attendance:

• If I attend my appointment, the $150 deposit may be applied toward treatment costs or refunded at my request.
• If the deposit is used or refunded and another orthodontic appointment is required, a new $150 deposit will be required to secure that booking.

4. Additional Consents

I acknowledge that I will be required to complete and sign new consent forms for each procedure performed at Goldfields Family Dental. This agreement does not replace the need for individual procedure-specific consent forms.

5. Patient Responsibilities

I agree to follow all oral hygiene, appliance care, and retainer instructions provided, attend scheduled appointments, and notify the practice as soon as possible if I am unable to attend an appointment.

6. Acknowledgement & Consent

I confirm that I have read and understood this Orthodontic Transfer Consent & Financial Agreement, have had the opportunity to ask questions, and agree to the terms outlined above.