Payment / Finance, Policies and Procedure Agreement:

Payment / Finance, Policies and Procedure Agreement:

(Please initial after each line and sign on the bottom)
Kishore Sunkara M.D.

669 Airport Frwy #401

Hurst, TX 76053
Patient Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
I understand that this office requires updated payment information which I will be asked for when making my first appointment.*
Initial
I understand that this information will be used for copays, future balances including No-Show charges.*
Initial
I understand that I will be responsible for full amount of payment for services rendered that may not be covered by my insurance.*
Initial
I understand that due to security reasons, I will provide updated payment information when necessary by phone or in person.*
Initial
I read all the policies and procedures and agree*
Initial
Signature of of patient / parent / guardian *

Clear
Date*

MonthDayYear
Date
After submitting this form, please complete our appointment request form, so that our office can reach out to you to set up the appointment.
Your Phone Number*
Please enter a valid phone number.
Should be Empty: