Financial Agreement (Patient Pays)

Financial Agreement

Payment Options:

• Cash, Check, Visa or Mastercard
• Convenient Monthly Payment Plans¹ from Carecredit
  • Allow you to pay over time
  • No annual fees or pre-payment penalties
  • No interest if paid in full within the 6 month or 12 month promotional period²

I agree to be responsible for all charges for dental services and materials. I understand that as a recipient of dental care I, the undersigned, am responsible, am responsible for all charges regardless of my circumstances for reimbursement. Full payment is due at the time our services are being provided to you.

1. Subject to credit approval
2. If promo and debt cancellation are not paid in full within the 6 months or 12 months, interest at 26.99% will be assessed from purchased date.

Acknowledgement of Receipt

I acknowledge that I have been offered a copy of Central Wisconsin Endodontics, LLC- Dr. Thomas C. Westrick’s NOTICE OFPRIVACY PRACTICES brochure and that I have a choice in whether I, physically, take one or not.