Signature will be recorded later.
Payment options will include cash, check, Visa, Mastercard, or American Express. All fees will be due at time of service, including co-pays and deductibles. For procedures requiring multiple visits, 50% of fees will be due at start of treatment and 50% will be due at completion. Every effort will be made to assist in calculating estimated insurance payments; however, I am aware that I am responsible for any non-covered services. I must notify Corner Dentistry of any appointment changes at least 24 hours in advance. If I break more than one appointment, I will be charged $25.First Name:Date: 10/22/2018Birthdate:Financial AgreementLast Name: