We invite you to discuss frankly with us any questions regarding services. The best health services are based on a friendly, mutual understanding between provider and patient. If your account is not paid within 90 days of the date of service, and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.
I understand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my health or insurance status.