Signature will be recorded later.
Date: 5/28/2017Our Policy requires payment in full for all the services render at the time of visit unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other charges incurred in collecting your account. If it is necessary to cancel an appointment, please do so at least 24 hours prior to your scheduled time so we may offer it to another patient. Your insurance is a contract between you, your employer and the insurance company. Informing you of your benefits and filling of your claims is a routine courtesy that we extend to our patients. We strive to provide you with accurate estimates of your share of cost based on the information provided by your insurance carrier. However, all charges are your responsibility form the date of services have stared. Any difference between what was estimated for you and what your insurance carrier actually pays will be your responsibility.Signature:Birthdate:First Name:Last Name:Financial Agreement