Sofia Colombo · Jun 2025 - Apr 2026
Service Provider
Dr. Elena Rossi
General & Cosmetic Dentist
info@rossidentalcare.com
Client
Sofia Colombo
sofia.colombo@email.com
Rossi Dental Care agrees to provide a complete porcelain veneer treatment plan for teeth #3 through #10 (8 veneers total), including all preparatory work, temporary veneers, and final placement over a 10-month period.
This agreement shall be effective from June 15, 2025 to April 30, 2026, covering the full treatment timeline including preparatory appointments and final placement.
The Patient agrees to pay $800 per month for 10 months ($8,000 total) for the duration of this agreement. Payment is due on the 15th of each month. This includes all preparatory appointments, temporary and permanent veneers, and one follow-up adjustment visit.
Patient may cancel with 30 days written notice. Refund will be prorated for unplaced veneers. Missed appointments without 24-hour notice will incur a $50 fee. Treatment timeline may be adjusted based on clinical assessment at each visit.
All treatment records and imaging remain the property of Rossi Dental Care. The Patient acknowledges that dental procedures involve inherent risks and consents to treatment after being informed of all options and potential complications.
Service Provider
Dr. Elena Rossi
Signature
Client
Sofia Colombo
Signature
Signed on June 12th, 2025