Payment Arrangements

Payment Arrangements
Dear Patient:

In an effort to provide you with flexible payment arrangements, we have expanded our payment policy.

PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT.
We now offer the following payment options:

Payment by cashPayment by checkPayment by credit cardAutomatic monthly billing to your Visa or MasterCardGuarantee any amount not covered by insurance with Visa or Mastercard
Please make your choice, sign below and return to office manager before treatment.

Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa or MasterCard to automatically cover amounts not paid by insurance. You may also choose a comfortable amount to be automatically billed to your Visa or MasterCard on a monthly basis.

If none of the above apply, please see the office manager. Thank you.
Print your name here
Signature

Clear
Should be Empty: