Financial Agreement

"*" indicates required fields

Our mission at Family Dentistry on Finch and Weston Dental is to provide excellence in dentistry that meets your individual needs. In order to reduce the cost of providing dentistry to our clients, payment is expected at the time of service.
We are pleased to offer the following payment options:

Option #1

Non-assignment of benefits with payment in full.

Payment is made in full by cash, interact, Visa, or MasterCard with non-assignment of your dental benefits. We will process your dental insurance claim for you and have the cheque sent directly to you within 3-5 business days.

Option #2

Deposit made day of treatment

Patient name*

agree to pay the fee of $

fee*

for the treatment

Treatment

I understand that the Lab fee must be paid in full the day the treatment begins.

Lab Fee

Lab Fee*

due

due*

Remaining balance

Remaining*

due

due*

Date*
MM slash DD slash YYYY

Client Name:
Full Name

Signature