Patient Information
Patient's Name
First Name
Middle Name
Last Name
Responsible Party
Self
Parent/Guardian
Responsible Party's Name
First Name
Middle Name
Last Name
Back
Next
Patient's Email
Confirmation Email
example@example.com
Financial Agreement
Treatment
Total Cost of Treatment
Insurance Portion
2% Credit Card Fee over $2000.00 Treatment
Partial Portion
Total due at First Appointment
Total Due at Second Appointment
Laboratory charges are estimated prices and may vary upon completion of treatment. This variation in turn might increase or decrease the total end price.
I Understand
Treatment over $2000.00 paid by Visa, MasterCard or American Express will have a 2% charge over treatment fees.
I Understand
By signing this document I am not committing to treatment at this time but understand the fees associated with this treatment.
I Understand
Patient's Signature
Patient's Name
First Name
Middle Name
Last Name
Responsible Party's Signature
Responsible Party's Name
First Name
Middle Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: