Common Contracts
1 similar Patient Information and Financial Agreement contracts
PATIENT INFORMATION and FINANCIAL AGREEMENTPatient Information and Financial Agreement • October 28th, 2015
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^ CREDIT CARD INFORMATION (REQUIRED): In the event your account becomes more than 30 days past due, I authorize Karina von Middendorf to debit my account for any unpaid fees that are considered my financial responsibility. Please print clearly and sign your authorization and agreement below.
