General Drop-Off Form

We will gladly prepare a written estimate if you desire; please ask Doctor or receptionist. Unless prior arrangements have been made, ALL PROFESSIONAL FEES ARE DUE AT THE TIME SERVICES ARE RENDERED. We accept MasterCard, Visa, Discover, and American Express. We also accept Care Credit and Scratch Pay, and extended service fees may apply. There will be a $30.00 service charge for any check returned unpaid or credit card declined. Accounts after 30 days are subject to a 21% APR or $9.00 monthly billing fee, whichever is greater. By signing below, I accept these billing terms