Financial Agreement

We are pleased to welcome you to our office. Please take a few minutes to fill out as completely as you can. If you have any questions we will be glad to help you.
Financial Agreement
Last Name
First Name
Birthdate
Date 10/22/2020
* 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.
I agree to let this office run a credit report. If no, then all fees are due at time of service.