Procedure Cost Estimate | Little Smiles

Patient & Appointment Details

Select the estimated minutes to match the official tier table. The deposit is $250. Complete the fields, initial each statement, then sign and submit.

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Patient & Appointment Info

Fill in all required fields before initialing

Patient Information

Patient Name *

Parent Phone Number *

Rendering Dentist *

Appointment Date

Estimated Procedure Minutes * Matches your printed estimate table

Notes (optional)

Review & Initial

Statement 1 of 3

* Initial Here

Sign here

The signed PDF is generated on the checkout computer and saved locally. This page requires initials for each statement and a final signature.

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Estimate Summary

Updates when you select minutes

Total Fee $—

Deposit Due Today $250

Balance Due at Appointment $—

📊 View Minutes → Fee Table

Minutes	Fee