Walk In Family Dental

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Financial agreement

Our mission at XXXXX 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
I,
agree to pay the fee of $
for the treatment
I understand that the Lab fee must be paid in full the day the treatment begins.
Lab Fee
due
Remaining balance
due
MM slash DD slash YYYY
Client Name:

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