IMPORTANT FINANCIAL TERMS and RELEASE:
I understand that I am responsible for all services provided and that full payment for surgery is due two (2) weeks prior to your procedure. Deposits are non-refundable and any credits will be honored for one (1) calendar year. Any amount 30 days past due will subject to 1.5% interest per month. I will also be responsible for any collection cost, court costs, filing fees and attorney feed. I authorize the release of any or all of my medical records to any health care provider, hospital, or other institution as deemed neccesary by Andrew P. Amunategui, MD and/or myself.
My signature below indicates that all of the information listed above is correct and that I agree to the terms listed above.