Skip to content
8321 Kennedy Rd#22 , Markham, ON L3N 5N4
thedentalhauz@gmail.com
Facebook-square
Instagram
Linkedin
Pinterest-square
Home
About Us
Services
Testimonial
FAQ’s
Forms
Contact Us
X
(905) 470-4289
Payment Agreement
Patient Name
Insurance coverage
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
8321 KENNEDY RD. UNIT # 22. MARKHAM, L3R 5N4 905.470.4289
Submit
