Signature will be recorded later.
* For my convenience, this office may release my information to my insurance company, and receive payment directly from them. * I understand that if I begin major treatment that involves lab work, I will be responsible for the fee at that time. * If sent to collections, I agree to pay all related fees and court costs. * Every effort will be made to help me with my insurance, but if they do not pay as expected, I will still be responsible. * I agree to pay finance charges of 1.5% per month (18% APR) on any balance 90 days past due. * I will pay a fee for appointments broken without 24 hours notice. * Treatment plans may change, and I will be responsible for the work actually done. * All charges that you incur at our office are your personal responsibility to pay. You may pay for your charges in full at each visit (and pursue your own reimbursement if desired) or choose to use our 3rd party payer filing service (dental insurance filing service).