Dental Treatment Plan & Fee Estimate

Based 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 Information

Patient name:

Chart number:

Plan prepared by (dentist):

Date:

Clinical Findings Summary

Key findings from exam and X-rays:

[Dentist writes clinical findings from exam and X-rays here]

Phase 1 — Urgent / Stabilizing Treatment

Procedures included and fees:

[Dentist itemizes Phase 1 procedures and fees here]

Phase 1 subtotal:

Phase 2 — Definitive / Restorative Treatment

Procedures included and fees:

[Dentist itemizes Phase 2 procedures and fees here]

Phase 2 subtotal:

Phase 3 — Elective / Cosmetic (optional)

Procedures included and fees (optional — deferred unless requested):

[Dentist itemizes Phase 3 procedures and fees here, if applicable]

Phase 3 subtotal:

Fees & Insurance

Total estimated fees (all phases):

Estimated insurance coverage:

Estimated patient responsibility (out of pocket):

Treatment Sequence & Schedule

Recommended order and approximate timeline:

[Dentist writes recommended treatment order and approximate timeline here]

Important Acknowledgments

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.

Patient Decision

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