Common Contracts

1 similar Payment Arrangement Agreement contracts

P AYMENT ARRANGEMENT FORM
Payment Arrangement Agreement • January 31st, 2016

Your dental health is our top priority, and the purpose of this agreement is to assist you in completing your necessary dental treatment in a timely manner to optimize your dental health. All figures provided are only an estimate, but we do strive to accurately predict insurance portions. Through the course of treatment, it may be necessary to change the treatment plan for a variety of unforeseen circumstances.

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