Beruflich Dokumente
Kultur Dokumente
Fax
To: R.E. Tuck DUDcan from; Donald R. Hoffinan
Fax; Pages: 6
Additional comments:
Enl;loscd please find the executed Order Establishing PlU'CDtingTime and a billing statement 8Jld
contract with Hamilton & Wilson Orthodontics. She needs to begin paying her share orthe enclosed
uninsured expenses.
Cordially,
DONALD R. HOffMAN
Attorney at Law
Raben E Duncan, II
AtlDmey at Law, t0924Z
2129N 8" Avenue. Suite 202
Topeka. KS SS603
(795)23~8S
Hal Richardson,
Petitioner
VI. CeseNo.980211
Claudine Dombrowski.
Respondent
hear1ng before the Court to establish parenting time. Petitioner appears in person by
and through his counsel Jason P. Hoffman. Respondent appears in person by and
through her counsel Robeft E. Ounce" II•. Jin Dykes, Guardian ad liIem appears. The
Court, having heard the statements of Counse'. having heaJd lhe statements of
unsupetviaed parenting time on Sundays from 1:00 p.m. unlil 3:00 p.m. The exchange
Otthoclontics Petitioner is to provide bills for said services as per Shawnee County
guidelir)e8:
4. There will be a "",iew heartng on March 2, 2010 lit 8:30 am. to evatuate
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...'-r.~.-
,
S. Prior orders regarding not uploading to the internet the child's image or references
to said child remain full force and in effect.
6. Further Respondent is not to discuss this case or any matters regarding the facts
giving rise to these proceedings wi.th the minor child.
7. The Guardian ad Litml will visit with the child after each visit to assess progress.
IT IS SO ORDERED.
APPROVED BY:
Jill Dykes
Guardian ad Litem
F. cassidy, D.D~., P.A. Paul8~ghl, D.D.S.,P.A. Steven Uslmstran, D.D.S.
,(D~Rsmilton, D.D.S., M.S.D •• P.A. MIrk L Underwaod, O.D.S., M.e-d.
~ B. Edmonds, 0.0.$., M.S.
~on CoWlleon. O.D.8. .
.~
Optilllum
-_ ~~-- ....•
orthodtmtic tWUftlf un '" KhieWJd with lnformtJd 8111lCGli/itmltiwJptIt/IInts. Onhodontlt:
treatment. bei", m MK:tiwt prtlCtldUffl, requiru undlm;ttlndirtlitif'the in""'t ~ INId'/tII'WIlll&.
'T'hcrtsJiIsre e/dQm enoufhto.make trtMtmtlnr iMdvi6tIbI •• but "'wld btl cOMidwrld.
1m ••••• TtItIa -In attempting 111move impacted teeth (teeth unable to etupt normally). especially CUlPids and third molars (wildom
tuih), 'arious problem. Ire wametimes encountered which may lead to gum and bone probl •••• , rei•••••• or'" or teeth. .
"ill Grawth Pattams - Unusual skeletal patterns and i"sutrlCient or undersirable facial grDyIth cen I;OftIprami ••••• onhodoatic
resulu, effect a facial change and cause shifting of teeth during retsntion. Surgical asslstance-mav"barecammend-.d in th8$1I siUi8tiON.
NamI1lll (0-1) ToatIt. A tooth traumatized by a blow or other cause can die over along period of urne with or without orthodontic
tteaunent,. This.tooth may discolor or f1ar. up during orth~ontlc:: movement and require endo~ tt'8Il1meM (root c.nal~. . .
OoRda_Cklcumnell •-At ~in times during the tnatment and retention, patients may exPerience •. varvln.. •••• of dllcomfort.
- They m-v allo notice feci.1 c •••• and speech chenges. -
UnIdtnd Ocicu•.••••• - e"",ts such • swallowing applJancet. chipping teeth, or dislodging lWStDI8ti0n5 occur inftllqUtntly_
PERIODoNTAL PROBLEMS (gum d••••• ) - This conditi~ can be present .before or dlIvelop during tmdmlnt. It cauld deteriorete
during trwaanent c:wiin.g laM of bone around the teeth along withstripping or gum reeeaiotr. Exeenllftt 0l1Il hVIi- and tnquent
: prophylaxis by your dentist Can help comrol this sitUal1on. .
-clio
FACT~WfncH THE PAnENT HAS SIGNIFICANT R~"UTV
COOPERAnON: In" walt m.jarItv of 0I'Ih0duut10c-. signIfIeInt imp••••••••• _ be •••••••••••.•••••••••••••••••
e-in u'"""" time lAffJIl/or
•••••piomind NIIIIta ••• OICUr tn.n nan ClOD.......... . ~~_
in.
.tCIt 91f:t101Jfirat/on fttIJowing
__ will PfOb/IlIfy taI/t inMMIIiInI flWtmtrnt timflMd~ MIl'" •.•.
_
••••• id••••.., T•••••• tnt Plan - Each individuel's trea1nIent is uniquw. Urt*rstanding and diligently foUowine InstrUl:tIonait IMP••
tive. This especillly involves individual. W8lIljDfJ,.8 retractor (htlldgear), functionll applienca. elllCtics. or. i1JtIiner.
WEARING RETRACTOR C••••• at -IELASrlCS- .•.•••• areforcel pIIC8d an ••• 10 _ win m •• into their ptapar PGlitiOMo .
Th. amount of time wom affecu •.•• 111. •••• as instrue'tildl If headgear is ••••••• fran the tubes or ••••••.• hookI while ttl. lll1tiC
fon::e is engaged. it can snip back and ClUstr-ilJj~r,;:_ . .
ceN at T_ •••• A,pO_. Poor tooth brushing incre •• therisk of dec8y when •••. Ing braca EJa:eIIlInIcnI~ ndudon
in •••••.• being selectilre in diet,. and reporting any loose bands .s ..-m as noticed, wiD t.fp minind ••••••••••••••••• (cIeIIci ••••.
110ft).and gum ~L Routine visits (3.6 m~' to your dlrntist for claning and GlVity checb .ra nec-y.
••• HabiII- Mau1h bre8thing. thumb, finger or lip sucking, or tongUe thlUSting (ebnarnlll ••• llawlng) co •••.•••• ptapIr •.••.•111
or cause reIIpse after brar;tIs 8nl remCMd.
KEEPINe APPOINTMEN18 • M'dhd appointmen1Sere_ m•• y lChedullng probI8mI.ncll •••••••en uaatment'" 8einI ccnIIIIn1ty
ll1tewiU"lOafft!ct_tmentti~Both wiUlintlt optimum results.
SCOTT D. HAMlLTON~ D.;D~S..;M.S:O.
DON C. WILSON, D.D.S.
You l'lav8 thB tfghl to receMt at lhIs limo an It4ImlmllOn Of UIe AMount FlnBnc!'d
a I WBn1en~" a I GO not -.nt an «-nizallan
PAYM&NTSCHS>ULE
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The Installment payments are due to be paid In full aaCh lJIOftth!( whatever period otbetwise'ureed upon). .
If a payment is more than 30 days late, you wUlbe charged ~10.001o each tatepayment.lfthenJisstiH a need. to requeslpayment,
you wiN reeeive a registered letter informing you that unlesa pay . .is made within a weet. W8 will ft~ It nllC8Sll8lY to funCllon
r,
for the. next lt1irty days in this manner: ,.... / .
1. We Will t~at only emergencies (this does not mean ~ treatment adJuatmenta).
2. We will-allow yOU to seek the servk:es of anoth8r:d8nt1stor.~ontistfO continue treatment.
3. We will remove the appliances aftIIr you have.ed a releeaeform.
If you failtopayyouraa:ount in 1uUdurlngthi$thltty-dayperiod, ot if you choosetoseektr8atmer1t8lsewheleorhIMltteepplilnces
. removed, an obligation on the partafouroffiCeceases. Atthattimeouroffk:e would. howtMIr. f8B9IV81herlghttocouec:.theamount
due us for the work WG have already completed. t '\ :'
-" a dleCk Is returned to 0111' offlce by the bank for any Nason there wIDbe a\faG.GO •••• med check charge. .
I agree to be responeibIe for any reasonable coIler:1fon costs or atIOmey f•••• ~ in CClftecfing 8 d8llnquent a.c:eount. .;
ORTHODONTIC eM.AGES '-_... "
OUr fee inctude8 reasonable orthodontic cam. DURING OATHODONTICSERVICES YOUR GENERAL DENT~ CARE AND
REGULAR EXAMS FOR CAVITIES ARE THE RESPONSIBIlITY OF YOUR R&GUlAR DENTIST. AddllIonaI charges Wi'll be
made for loet or broken appllancesorfar nan-eoopeftltlon.by the patient after dlsc:usslon wIIh the ruponaible party. Our services
wIDbe diecontlnued for lack of cooperatlon orfailUnli to eclhere to me abOve financial agl8Bmenl We schedule our appoillbnenls
at cne to eigm week intervals. The fnlqUl!!ncy of appointmeo1ts has no bearfng on tile fee. .•....
Mditional phases of b8atrnanf may be needBd, especially if in phase I or early tteetment. and may I1IquInJ addItIcnai fees. The
t'88 inc:ludes offtce vlslt8 and rad'lOg18phS tor up to two years of retention after which 1het8 will be a fee far additio"a1 services as
needed.
'n the event "t we are unable to complete lite couree of llCtiVe orttlOdontk: InIa1menl clIe to the Patients moving from 1he
community, or for oIher unfontseeabIe reasons, it Ia to be mutually understood Ihat the account w'all be ~ted and adjusted
according to aClUal services remfered up to 111Moftran8fet. There wDl be a charge for duplication and transfer of records. UnCfer
such cohditions, no further obligation win be eseumed by Ots. Hamnlan and WHson, P.A. .
To avoid any misund&rstandlng, we will be heppy to di9cuss.the abtMt lnfOrmaIIon Wilh yOU.
---- PlEASE. ~ILeTHIS Le;rTERFOR FUTUAE REFERENCE _
:23.5SWWestport Drive
Topeka. KS 66614
(78S) 172-3722
PATIENT CONTRACT
? A T I E N T
CHARGE TP CHARGE TP CHARGE TP CHARGE T?
t:t-M NovO 9 150.00 C 13 Nov10 150.00 C 25 Nov 11 150.00 C 37 Nov12
y~ Dec09 150.00 C 14 DeclO 150.00 C 26 Dec11 150.00 C 38 Dec12
. 81& Janl0 150.00 C 15 Jan11 150.00 C 27 Jan12 150.00 C 39 Jan13
04 PeblO 150.pO C 16 Febl1 150.00 C 28 Feb12 150.00 C 40 Feb13
05 MarlO 150.00 C 17 Marll 150.00 C 29 Mar12 150.00 C 41 Marl 3
06 Apr10 150.00 C 18 Aprll 150.00 C 30 Apr12 135.00 C 42 Aprl3
07 Mayl0 150.00 C 19 May11 150.00 C 31 Mayl2 43 May13
08 JunlO 150.00 C 20 Junll 150.00 C 32 Jun12 44 Jun13
09 Jul10 150.00 C 21 Ju111 150.00 C 33 Jul12 45 Jul13
10 AuglO 150.00 C 22 Augll 150.00 C 34 Aug12 46 Augl3
11 SeplO 150.00 C 23 Sepll 150.00 C"35 Sep12 47 Sep13
12 OctlO 150.00 C 24 Oct!1 150.00 C 36 Oct12 48 Oct13