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About Us
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Contact
Home
About Us
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Contact
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About Us
Services
Forms
Contact
Dental Treatment Payment Agreement
Patient Name
Treatment
Appointment 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, 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.
Date
Dental Office Representative Signature
8321 KENNEDY RD. UNIT # 22. MARKHAM, L3R 5N4 905.470.4289
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