Financial Agreement
Financial Agreement
Last Name
Last Name is a required field
First Name
First Name is a required field
Invalid Date of Birth. Format MM/dd/yyyy
Birthdate
Birthdate is a required field
Date 12/3/2024
* 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.
Yes
No