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About Us
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Home
About Us
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Home
About Us
Services
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Contact
Home
About Us
Services
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Contact
Home
About Us
Services
Forms
Contact
Payment Agreement
Patient Name
Insurance coverage
Payment Agreement Terms
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. A 3% additional charge may apply if payment is made using any card other than debit/e-transfer.
Your credit card will be securely kept on file for any uncovered treatment costs.
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.
Patient Signature
Date
Dental Office Representative Signature
Date
8321 KENNEDY RD. UNIT # 22. MARKHAM, L3R 5N4 905.470.4289
Submit