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Expense Form
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Expense Form
First Name
Last Name
Date of Service
Week Ending
Patient total
Patient Payment ($)
Balance
Payment Type
Check
Cash
Credit / Debit Card
Warranty work?
No
Yes
Procedures - Select Multiple Procedures (Select only the procedures that will be completed soon (1 to 2 pay periods). If the patient is not required to pay the total cost, please do not select the Procedures.
Adjustments
Bone Graft
Bridge PFM
Bridge Zr
Cleaning Deep
Cleaning Surgical Periodontal
Cleaning Ultrasonic
Crown PFM
Crown PFM Implant
Crown Zr
Crown Zr Implant
Crown Temporary
Denture Temporary
Denture (Regular or Implant)
Denture Reline
Denture Repair
Exam
Extraction - non-surgical
Extraction - surgical
Filling
Flipper
Implant Abutment or Locator
Implant Placed for Single Tooth
Implant(s) Placed for Bridge
Implants Placed for Denture 2in1
Implants Placed for Denture 3in1
Implants Placed for Denture 4in1
Insurance
Night Guard
Partial
Partial Repair
Root Canal
Root Canal post
Sedation Mild or Unconscientious
Sinus Lift
XRay 3D
Adjustments
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Bone Graft
Quantity
Tooth #
Specialist Procedure Cost
Dr.'s
--SELECT--
DR FAMANIA $175
DR ELIO $200
DR ARENAS $180
DR JULIO ORTIZ $140
DR MATEO $150
DR JUAN CARLOS $200
DR JOSE CARLOS MORALES $140
DR. JARI FRANCO $160
INDIVIDUAL $550
PAQUETE $500
BONE GRAFT $100
LOCATORS $200
DENT IMPLANTE $700
ALVOLOPLASTY $150
ABUTMENT $ 150
HOUSINGS / CAPSULA $40
WHITENING BY MONICA $200
DR ELIO $250
DR FAMANIA $50
DR ELIO $50
DR. MATEO $50
DR. JULIO $40
DR. ARENAS $70
DR. ARENAS RECONSTRUIDA $40
EXTRACCION NORMAL $50
MUELA DE JUCIO $100
DIENTE RETENIDO $150
IMPLANTE $450
EXTRAC HUESO IMPLANTE $600
EXTRA HUESO $150
HUESO $100
TORUS $100
ELEVACION DE SENO $500
REGULARIZACION $100
BICHECTOMIA $350
APICECTOMIA $100
ALARGAMIENTO DE CORONA $80
FRENILOCTOMIA $100
ALVEOLITIS $40
RECEMENTAR CORONAS MP $25
ORINGS $35
DENTURE REMOVAL TOOL $25
PASTILLA VALIUM $10
PASTILLA TRIAZOLOM $15
3D XRAY $250
LOCATOR $550
ABUTMENT $550
RECEMENTAR CORONAS ZIRC $50
ENDO SOBRE CORONA DR ELIO $250
Bridge PFM
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Bridge Zr
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Cleaning Deep
Quantity
Tooth #
Specialist Procedure Cost
Dr.'s
--SELECT--
DR FAMANIA $175
DR ELIO $200
DR ARENAS $180
DR JULIO ORTIZ $140
DR MATEO $150
DR JUAN CARLOS $200
DR JOSE CARLOS MORALES $140
DR. JARI FRANCO $160
INDIVIDUAL $550
PAQUETE $500
BONE GRAFT $100
LOCATORS $200
DENT IMPLANTE $700
ALVOLOPLASTY $150
ABUTMENT $ 150
HOUSINGS / CAPSULA $40
WHITENING BY MONICA $200
DR ELIO $250
DR FAMANIA $50
DR ELIO $50
DR. MATEO $50
DR. JULIO $40
DR. ARENAS $70
DR. ARENAS RECONSTRUIDA $40
EXTRACCION NORMAL $50
MUELA DE JUCIO $100
DIENTE RETENIDO $150
IMPLANTE $450
EXTRAC HUESO IMPLANTE $600
EXTRA HUESO $150
HUESO $100
TORUS $100
ELEVACION DE SENO $500
REGULARIZACION $100
BICHECTOMIA $350
APICECTOMIA $100
ALARGAMIENTO DE CORONA $80
FRENILOCTOMIA $100
ALVEOLITIS $40
RECEMENTAR CORONAS MP $25
ORINGS $35
DENTURE REMOVAL TOOL $25
PASTILLA VALIUM $10
PASTILLA TRIAZOLOM $15
3D XRAY $250
LOCATOR $550
ABUTMENT $550
RECEMENTAR CORONAS ZIRC $50
ENDO SOBRE CORONA DR ELIO $250
Cleaning Surgical Periodontal
Quantity
Tooth #
Specialist Procedure Cost
Dr.'s
--SELECT--
DR FAMANIA $175
DR ELIO $200
DR ARENAS $180
DR JULIO ORTIZ $140
DR MATEO $150
DR JUAN CARLOS $200
DR JOSE CARLOS MORALES $140
DR. JARI FRANCO $160
INDIVIDUAL $550
PAQUETE $500
BONE GRAFT $100
LOCATORS $200
DENT IMPLANTE $700
ALVOLOPLASTY $150
ABUTMENT $ 150
HOUSINGS / CAPSULA $40
WHITENING BY MONICA $200
DR ELIO $250
DR FAMANIA $50
DR ELIO $50
DR. MATEO $50
DR. JULIO $40
DR. ARENAS $70
DR. ARENAS RECONSTRUIDA $40
EXTRACCION NORMAL $50
MUELA DE JUCIO $100
DIENTE RETENIDO $150
IMPLANTE $450
EXTRAC HUESO IMPLANTE $600
EXTRA HUESO $150
HUESO $100
TORUS $100
ELEVACION DE SENO $500
REGULARIZACION $100
BICHECTOMIA $350
APICECTOMIA $100
ALARGAMIENTO DE CORONA $80
FRENILOCTOMIA $100
ALVEOLITIS $40
RECEMENTAR CORONAS MP $25
ORINGS $35
DENTURE REMOVAL TOOL $25
PASTILLA VALIUM $10
PASTILLA TRIAZOLOM $15
3D XRAY $250
LOCATOR $550
ABUTMENT $550
RECEMENTAR CORONAS ZIRC $50
ENDO SOBRE CORONA DR ELIO $250
Cleaning Ultrasonic
Quantity
Specialist Procedure Cost
Dr.'s
--SELECT--
DR FAMANIA $175
DR ELIO $200
DR ARENAS $180
DR JULIO ORTIZ $140
DR MATEO $150
DR JUAN CARLOS $200
DR JOSE CARLOS MORALES $140
DR. JARI FRANCO $160
INDIVIDUAL $550
PAQUETE $500
BONE GRAFT $100
LOCATORS $200
DENT IMPLANTE $700
ALVOLOPLASTY $150
ABUTMENT $ 150
HOUSINGS / CAPSULA $40
WHITENING BY MONICA $200
DR ELIO $250
DR FAMANIA $50
DR ELIO $50
DR. MATEO $50
DR. JULIO $40
DR. ARENAS $70
DR. ARENAS RECONSTRUIDA $40
EXTRACCION NORMAL $50
MUELA DE JUCIO $100
DIENTE RETENIDO $150
IMPLANTE $450
EXTRAC HUESO IMPLANTE $600
EXTRA HUESO $150
HUESO $100
TORUS $100
ELEVACION DE SENO $500
REGULARIZACION $100
BICHECTOMIA $350
APICECTOMIA $100
ALARGAMIENTO DE CORONA $80
FRENILOCTOMIA $100
ALVEOLITIS $40
RECEMENTAR CORONAS MP $25
ORINGS $35
DENTURE REMOVAL TOOL $25
PASTILLA VALIUM $10
PASTILLA TRIAZOLOM $15
3D XRAY $250
LOCATOR $550
ABUTMENT $550
RECEMENTAR CORONAS ZIRC $50
ENDO SOBRE CORONA DR ELIO $250
Crown PFM
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Crown PFM Implant
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Crown Zr
Quantity
Tooth #
Procedure Cost
Laboratory Name
--Select Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Crown Zr Implant
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Crown Temporary
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Denture Temporary
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Denture (Regular or Implant)
Quantity
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Denture Reline
Quantity
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Denture Repair
Quantity
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Exam
Quantity
Procedure Cost
ADC Name
ADC Payment
Extraction - non - surgical
Quantity
Tooth #
Procedure Cost
Specialist Name (if surgical)
Specialist Name (if surgical) Payment
Extraction - surgical
Quantity
Tooth #
Procedure Cost
Specialist Name (if surgical)
Specialist Name (if surgical) Payment
Filling
Quantity
Tooth #
Procedure Cost
Dentist Name
Dentist Payment
Flipper
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Implant Abutment or Locator
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Implant Placed for Single Tooth
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Implant(s) Placed for Bridge
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Implants Placed for Denture 2in1
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Implants Placed for Denture 3in1
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Implants Placed for Denture 4in1
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Insurance
Quantity
Procedure Cost
Assistant's Name
Assistant's Payment
Night Guard
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Partial
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Partial Repair
Quantity
Tooth #
Procedure Cost
Laboratory Name
--SELECT Laboratory Name--
GOYO LAB
JUNIOR LAB
TETO LAB
GARANTIAS LAB
BETO LAB
FABIAN LAB
Laboratory Price
Root Canal
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Root Canal post
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Sedation Mild or Unconscientious
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Sinus Lift
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
XRay 3D
Quantity
Tooth #
Specialist Procedure Cost
Dentist Name
Dentist Payment
Lab Fees
Specialist Procedures
General Dentistry
General Dentistry PAYMENT
Is the treatment complete?
Yes (Select this if it will be complete this pay period or the next)
No (Select this if it will be 1 month or more to complete)
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Expense Form
