Dental Clinic Pro Toolkit
A complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperA complete toolkit for established dental clinics, including an annual care membership agreement and an in-depth orthodontic progress review
Get started with PocperBased on your examination, we've put together the treatment plan below with itemized fees. Please review each step, the expected sequence, and the out-of-pocket costs. Once you sign below, we'll prepare the individual treatment consent forms and begin scheduling.
Patient name:
Chart number:
Plan prepared by (dentist):
Date:
Key findings from exam and X-rays:
[Dentist writes clinical findings from exam and X-rays here]
Procedures included and fees:
[Dentist itemizes Phase 1 procedures and fees here]
Phase 1 subtotal:
Procedures included and fees:
[Dentist itemizes Phase 2 procedures and fees here]
Phase 2 subtotal:
Procedures included and fees (optional — deferred unless requested):
[Dentist itemizes Phase 3 procedures and fees here, if applicable]
Phase 3 subtotal:
Total estimated fees (all phases):
Estimated insurance coverage:
Estimated patient responsibility (out of pocket):
Recommended order and approximate timeline:
[Dentist writes recommended treatment order and approximate timeline here]
I understand this is an estimate; actual fees may change if additional treatment is needed or discovered during procedures.
I understand insurance coverage is an estimate based on my plan and is not a guarantee of payment.
I understand a separate written consent form will be provided before each major procedure.
I have had the opportunity to ask questions and my questions have been answered to my satisfaction.
I accept the full treatment plan as presented
I accept Phase 1 and Phase 2 only (no elective work)
I need more time to decide — please contact me
The Dental Treatment Plan & Fee Estimate template is a ready-to-use form from Pocper's Dental Clinic Pro Toolkit pack. Customize the fields to match your workflow, then share a link so clients can complete it and upload documents in real time.