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

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

Dental Treatment Payment Agreement

Important Link

Our Services

Get in Touch