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Expense Form

Payment Type

Warranty work?

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.


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


Extraction - non - surgical

Extraction - surgical



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


Night Guard


Partial Repair

Root Canal

Root Canal post

Sedation Mild or Unconscientious

Sinus Lift

XRay 3D

Is the treatment complete?