Financial No-Insurance Authorization

Please correct the errors described below.

Financial Agreement

Payment Option

  • Cash, Check, Visa or Mastercard
  • Convenient Monthly Payment PlansĀ¹ 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 periodĀ²

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.

Acknowledge of Receipt

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

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