PLD New Patient Agreement To Pay

PROFESSIONAL LANE DENTAL ASSOCIATES
102 Professional Lane
Dothan, AL 36303

Patient Name*

First NameLast Name

Patient Date Of Birth*

Date

Responsible Party*

First NameLast Name

Responsible Party Date Of Birth*

Date

Please Note Areas With Red * Must Be Completed, Signed and Agreed To

We now accept Credit Card payments via Clover.

AGREEMENT TO PAY:
You will be expected to pay deductibles and co-pays at the time of service. We accept cash, checks, credit cards & Care Credit.

The undersigned accepts the fees charged as a legal and lawful debt and agrees to pay said fees, including any/all collection agency fees, (33.33%), attorney fees and/or court fees, if such be necessary.

You agree, in order for us to service your account or to collect monies you may owe, PROFESSIONAL LANE DENTAL and/or our agents, may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide to use. Methods of contact may include using pre-recorded/artificial voice messages and/or use of automatic dialing device, as applicable.

I/We have read this disclosure and agree that PROFESSIONAL LANE DENTAL, its employees and/or agents may contact me/us as described above.*

Agree

Full Signature Required For Agreement To Pay Signature*

Broken Appointments Fee

Appointments that are canceled with less than 24-hour notice may be subject to a $35.00(hygiene)/$50.00(dentist) broken appointment fee.

Agree To Broken Appointment Fee*

Agree

Initial Broken Appointment Fee*

Deductibles and Co-Payments

All deductibles and co-payments are due on the day of treatment unless prior arrangements have been made with the Office Manager.

Agree To Deductibles and Co-Payments*

Agree

Initial Deductible and Co-Payments*

PROFESSIONAL LANE DENTAL PRIVACY PRACTICES
To proceed you must review and agree to our privacy practices below.

Scroll down to Submit after agreeing.

By checking the box (Below Privacy Practices) You are agreeing that you have read and agree to the Privacy Practices.*REQUIRED*

Initial Read The Privacy Practices*