Dental Treatment Payment Agreement

Patient Name

Treatment

Appointment date

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

Full name of patient

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 Type the name of the representative who signs for the office.

8321 Kennedy Rd #22, Markham, ON L3R 5N4 · (905) 470-4289