Monthly Payment Plan Agreement

Monthly Payment Plan Agreement
Thank you for the confidence you have placed with us by allowing us to participate in your child's healthcare. We hope to continue to build life-long relationships between our staff, our patients, and their families.
Today's Date*

MonthDayYear
Date
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
I agree to pay $ amount* per month on my child's account until my balance has been cleared. I authorize Waggoner Pediatrics to automatically charge my credit card for the previously stated amount each month.
Parent / Legal Guardian Name*

First NameLast Name
Parent / Legal Guardian Signature*
Should be Empty: