Fee Estimate

Simple form to present fees

Confusion about treatment and fees is the number
One patient complaint with State Dental Boards.

Stop this from happening!

This easy-to-use and simple form may be used to present fees and financial arrangements to patients. Less comprehensive than the Treatment Estimate C-112L, this form is more than adequate for most treatment conferences. It documents financial arrangements and supplements the informed consent process (Click on Informed Consent Forms on products page). Use this form to eliminate confusion about treatment and fees.

  • Financial arrangements to fit any office
  • Most common dental treatment procedures on one simple form
  • Basic informed consent 
C-212L Fee Estimate
$18.00 / 200 $34.00 / 400
$64.00 / 800 $120.00 / 1600



To preview
Sample Form in PDF format






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