Orthodontic Agreement & Policies

Scheduling, Late Arrivals & Patient Communication

If you are unable to keep a scheduled appointment with our office, or if you miss a scheduled appointment, please contact us as soon as possible to reschedule. We will reschedule you in the next available opening.

If you arrive more than 10 minutes late for a scheduled appointment, we must reschedule your appointment. We reschedule late patients so that all our patients (including you) will not have to wait due to late arrivals. If you are more than IO minutes late and would like to wait, we are happy to work you into our schedule if there is an opening available.

You agree to electronic communications, and you agree that Burke and Beckstrom Orthodontics is not obligated to provide any communications to you in paper form unless you specifically request us to do so.

Emergencies & Broken Brackets/Appliances

If you or the patient knows of a problem (broken bracket, etc.) prior to the patient’s regular appointment, please notify us of the nature of the problem before your appointment so we can schedule a time to correct the issue. This may require rescheduling your appointment to better serve you. Although loose bands, broken brackets, etc. are problems that can occur during orthodontic treatment, if you have an excessive amount of these issues, we reserve the right to charge a $25 fee per broken bracket or other orthodontic issue.

If you have an emergency on the weekend or evenings after hours that cannot wait until the following business day, please call (435) 673-3334 and a member of our orthodontic team will be available to discuss your emergency with you.

Orthodontic Insurance

Burke and Beckstrom Orthodontics will be happy to attempt to verify available orthodontic benefits, and submit insurance claim forms. However, we cannot guarantee the actual payments by your insurance carrier. This is only an estimate. Any insurance balance that has not been paid at the end of treatment is your responsibility as the account holder.

Financial Agreement

The fee charged is an all-inclusive fee for the orthodontic services provided. Monthly payment schedules provide a convenient budgeting method, but the value of the treatment is not represented by the monthly payments. Treatment may be completed prior to the end of the monthly payment contract, but payment is still required until the contract has been satisfied.

You promise to pay the amount financed on the dates and in the amounts provided in the Recurring Payment Plan. You may prepay this amount at any time in full or in part.

If payment is not made within 60 days of its due date, a late payment fee of $25 will be assessed. Active treatment will be suspended on patients whose accounts are more than 60 days past due. We will attend to the emergency needs only until the account is brought current. Orthodontic appliances will not be removed until all outstanding fees are paid in full. Accounts that become more than 90 days past due may be referred to an outside collection agency and a collection fee of 30% will be added to your outstanding balance. If treatment is extended due to poor patient cooperation and/or missed appointments, an additional fee of $150 per month or $150 per visit may be charged.


Once the orthodontic appliances are removed, the retention phase of treatment begins. In order to keep your teeth and bite from moving, you must now wear your retainers as the doctor has prescribed. If you neglect to wear your retainers as prescribed and your teeth shift or move, you agree that any orthodontic retreat needed will be your financial responsibility. If at any time, during your retention phase of treatment, you have any concerns, problems or discomfort with your retainers, contact us immediately so that we can help to resolve these issues before your teeth do shift or move. The total treatment fee includes one set of retainers (one upper arch and one lower arch), and one appointment to confirm the proper fit of retainers. You acknowledge that the Burke and Beckstrom Orthodontics Retainer Replacement Plan has been offered to you. If you decline this Replacement Plan, you understand that you will be charged $200 per retainer for any replacement retainers needed. Payment is due prior to the fabrication and delivery of retainers.

If you have Medicaid insurance, and you are no longer eligible for Medicaid at the end of your orthodontic treatment, you agree that if you desire retainers, you will be charged $200 per arch for retainers. Payment is due prior to the fabrication and delivery of retainers.

I hereby certify that I have read this Orthodontic Agreement and Policies in full, and I agree to abide by the terms set forth herein.

Media Release

I authorize or decline Burke and Beckstrom Orthodontics to use my/my child’s picture(s) on Facebook, Instagram, and/or other social media, as well as on the Burke and Beckstrom Orthodontics website, for marketing purposes only; or for educational purposes, including presentations with other patients or with other doctors.

Consent for use and disclosure of Health Information and Records

Please read the following statement carefully:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available at our front desk. We encourage you to read it carefully and completely before signing this Consent.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to this office. Please understand that revocation of the Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

I have had the full opportunity to read and consider the contents of the Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information as described in the “Notice of Privacy Practices.”