Invisalign^® Submission Fee Form

Name: Wired Orthodontics
Telephone: 07 3260 6855

To start your Invisalign^® treatment at Wired Orthodontics, a $300 submission fee is required at the time of booking your Invisalign^® fitting appointment. This will be taken away from the total cost of your treatment.

The submission fee demonstrates your commitment to proceeding with the proposed treatment and your aligners will immediately go into production phase. Once your aligners are in production, the order cannot be cancelled and Align Technology will charge us a production fee of approximately $2200 - $3850. This production fee cannot be recovered/refunded.

Upon paying the submission fee, you acknowledge that:

You are agreeing to proceed with the proposed Invisalign^® treatment as quoted.
If you decide to cancel your treatment, you will be liable to pay the remaining balance of the production fees in full to Wired Orthodontics (however you will not be charged the full cost of treatment).
Your aligners are a custom-made appliance which can only be used for your teeth!

As a courtesy to our patients and to help make treatment more affordable, we offer this reduced submission fee of $300 as opposed to charging a larger upfront deposit that will cover the cost of the production fees.

Please fill in all fields marked with *

Patient First Name*

Patient Last Name*

Patient Email*

Guardian Name

Relationship to patient

Date*

Fields marked * are required.

Signature of Patient or Parent/Guardian (If patient is under the age of 18)*