Payment Options:
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.
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.
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