Repulse Bay Office
Fee Arrangement
Personal Information
Date*
Name*
Phone Number*
Email*
Fee Items
Fee Items
Please Select
Orthodontics Clear Aligner - Full Mouth
Orthodontics Fixed Appliance Therapy (Ceramic)
Orthodontics Fixed Appliance Therapy (Metal)
Orthodontics Fixed Appliance Therapy (Metal) - Partial
Orthodontics Fixed Palatal Expansion Therapy
Orthodontics Functional Appliance
Orthodontics Mixed Therapy
Orthodontics Removable Appliance
Orthodontics - Biteplate
Orthodontics - Facemask
Orthodontics - Lip Bumper
Orthodontics - Mini implant (Per Screw)
Orthodontics - Myobrace
Others (Please Specify)
Others - Not Calculated (Please Specify)
Price
Please Select
Orthodontics Clear Aligner - Full Mouth
Orthodontics Fixed Appliance Therapy (Ceramic)
Orthodontics Fixed Appliance Therapy (Metal)
Orthodontics Fixed Appliance Therapy (Metal) - Partial
Orthodontics Fixed Palatal Expansion Therapy
Orthodontics Functional Appliance
Orthodontics Mixed Therapy
Orthodontics Removable Appliance
Orthodontics - Biteplate
Orthodontics - Facemask
Orthodontics - Lip Bumper
Orthodontics - Mini implant (Per Screw)
Orthodontics - Myobrace
Others (Please Specify)
Others - Not Calculated (Please Specify)
Please Select
Orthodontics Clear Aligner - Full Mouth
Orthodontics Fixed Appliance Therapy (Ceramic)
Orthodontics Fixed Appliance Therapy (Metal)
Orthodontics Fixed Appliance Therapy (Metal) - Partial
Orthodontics Fixed Palatal Expansion Therapy
Orthodontics Functional Appliance
Orthodontics Mixed Therapy
Orthodontics Removable Appliance
Orthodontics - Biteplate
Orthodontics - Facemask
Orthodontics - Lip Bumper
Orthodontics - Mini implant (Per Screw)
Orthodontics - Myobrace
Others (Please Specify)
Others - Not Calculated (Please Specify)
Please Select
Orthodontics Clear Aligner - Full Mouth
Orthodontics Fixed Appliance Therapy (Ceramic)
Orthodontics Fixed Appliance Therapy (Metal)
Orthodontics Fixed Appliance Therapy (Metal) - Partial
Orthodontics Fixed Palatal Expansion Therapy
Orthodontics Functional Appliance
Orthodontics Mixed Therapy
Orthodontics Removable Appliance
Orthodontics - Biteplate
Orthodontics - Facemask
Orthodontics - Lip Bumper
Orthodontics - Mini implant (Per Screw)
Orthodontics - Myobrace
Others (Please Specify)
Others - Not Calculated (Please Specify)
Please Select
Orthodontics Clear Aligner - Full Mouth
Orthodontics Fixed Appliance Therapy (Ceramic)
Orthodontics Fixed Appliance Therapy (Metal)
Orthodontics Fixed Appliance Therapy (Metal) - Partial
Orthodontics Fixed Palatal Expansion Therapy
Orthodontics Functional Appliance
Orthodontics Mixed Therapy
Orthodontics Removable Appliance
Orthodontics - Biteplate
Orthodontics - Facemask
Orthodontics - Lip Bumper
Orthodontics - Mini implant (Per Screw)
Orthodontics - Myobrace
Others (Please Specify)
Others - Not Calculated (Please Specify)
Payment
Initial Payment (%)*
Please Select
50%
100%
None
Others % (Please specify)
Others Amount (HK$) (Please specify)
Installment*
Please Select
None
1-1
1-2
1-10
1-20
Others (Please Specify)
Remark
CONSENT
Patient or Parent's signature*
