I agree to the following:
In signing below;
- I agree to pay for all services not covered under agreement of my treatment.
- I will pay for all services prior to my appointment and any back balances I have accrued that is not covered through my insurance and / cash pay patients
- I understand that all copays, co-insurances and / or self payments will be due at time of service with the full understanding that failure to do so may result in having to reschedule my appointment to the NEXT AVAILABLE appointment if my obligations are not fulfilled, unless otherwise agreed upon by the provider or office manager.
- I understand that my medication will be sent to the pharmacy at the time of my appointment after being seen by the provider and NO bridges of medication will be provided.