Common Contracts
1 similar Financial Agreement contracts
PATIENT INFORMATIONFinancial Agreement • September 9th, 2021
Financial arrangements will be made with you before any treatment is rendered. All emergency dental treatment or any dental treatment performed without prior financial arrangements will be paid for at the time of service. Patients who carry dental insurance understand that all dental treatment provided is performed directly for the patient and that you or your responsible party is personally responsible for payment of all treatment. A service charge of 21 per annum may be charged on the unpaid balance of all accounts over 60 days. I understand that when appropriate, credit bureau reports may be obtained. I grant my permission to your office to telephone me at my home or work to discuss matters related to this form or my dental treatment.
