Payment Plan

Dear Patient:

In an effort to provide you with flexible payment arrangements, we have expanded our
payment policy.

PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT.

We now offer the following payment options:

• Payment by cash
• Payment by check
• Payment by credit card
• Guarantee any amount not covered by insurance with Visa or MasterCard
• Automatic monthly billing to your Visa or MasterCard (Please ask for the Autopay form.)

Please make your choice, sign below and return to office manager before treatment

Our office is a fully approved and accredited user of the Visa and MasterCard Health Care
Program which will enable you to use your Visa and MasterCard to automatically cover amounts
not paid by your insurance. You may also choose a comfortable amount to be automatically
billed to your Visa or Mastercard on a montly basis.

If none of the above apply, please see the office manager. Thank you.