Dental Treatment Payment Agreement

Dental Treatment Payment Agreement
Patient Name
Treatment
Appointment date

MonthDayYear
Date
Payment Breakdown
Primary Insurance Contribution
Secondary Insurance Contribution
Patient Portion
Deposit Due Prior to Appointment
Remaining Balance Due at Appointment
Additional Terms
- A 3% additional charge applies if payment is made using any card other than debit/e-transfer.
- Patients are responsible for full payment of services regardless of insurance coverage.
- If insurance does not cover the estimated amount, the patient agrees to pay any remaining balance.
Patient Acknowledgment
I, Full Name , acknowledge that I have read and understand the above payment agreement. I agree to the terms stated and accept financial responsibility for the services provided.
Patient Signature

Clear
Date

MonthDayYear
Date
Dental Office Representative Signature

Clear
Date

MonthDayYear
Date
Dr. Summer Al Maqdassy & Associates

Laurier Dental: 500 Laurier Ave Milton Ontario L9T 4R3

905 878 9882

info@laurierdental.ca
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