The
following treatment plan has three key areas (Report of Findings,
Treatment Planning Worksheet and Financial Arrangements) that you will
be presented with by your
dentist. Each area should be carefully reviewed with your dentist, and you should ensure
that any and all questions you have are answered to your complete understanding.
Jeffrey S. Cummings, DMD
Waltham, Massachusetts
REPORT OF FINDINGS
Analysis For (patient name)
Date
___________
| The Following Diagnostic Records Were
Analyzed: 1. Full Mouth X-Ray
2. Panoramic Radiographs
3. Periodontal Charting
4. Oral Exam of Existing Restorations
5. Occlusal Analysis
6. Study Models
7. Photographic Series
8. Preview Models |
The Following Risk Factors Were Noted: 1. ____________________________
2. ____________________________
3. ____________________________
4. ____________________________
5. ____________________________
6. ____________________________
7. ____________________________
8. ____________________________ |
Problems:
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- _____________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
- ______________________________________________________
|
Jeffrey S. Cummings, DMD
Waltham, Massachusetts
TREATMENT PLANNING WORKSHEET
Treatment For
Date
___________
STABILIZATION PHASE
(Perio, equilibration, immediate restorative, emergency)
1. ____________________________
2. ____________________________
3. ____________________________
4. ____________________________
5. ____________________________
6. ____________________________
|
REFERRAL PHASE
(Get opinions or start treatment by specialist)
1. ____________________________
2. ____________________________
3. ____________________________
|
RESTORATION/COSMETIC
PHASE
1. ____________________________
2. ____________________________
3. ____________________________
4. ____________________________
5. ____________________________
6. ____________________________
|
PROTECTION PHASE
(Dental appliance, recall)
1. ____________________________
2. ____________________________
3. ____________________________
4. ____________________________
5. ____________________________
6. ____________________________
|
|
Jeffrey S. Cummings, DMD
Waltham, Massachusetts
FINANCIAL ARRANGEMENTS
Patient
Date
___________
| The approximate fee for your treatment
is: _________________ Stabilization /
Restoration Phase **
_________________ Cosmetic and/or Crown Phase
_________________ Protection Phase
_________________ Total
|
** additional charges may be incurred
as treatment dictates
(e.g. root canal therapy or periodontal surgery)
PAYMENT OPTIONS
| Option 1: |
Prepayment in full with a 5% discount. |
| Option 2: |
Dental Fee Plan
An affordable option at very reasonable rates
0% Down: No Application Fee: No Initial Payment |
Payment plans ranging from
18-60 months with low fixed interest rates of 9.99% to 12.99% depending on the term
selected.
Prepayments to Dental Fee Plan can be made anytime without penalty. |
 
|
