New Patient Form

Payment is due in full at the time services are rendered. We accept cash, checks, all major credit cards, Care Credit, and ScratchPay. A $30.00 service charge will be applied to any checks returned unpaid. Any accounts having a balance will be charged a service fee of 1.5% per month (18% per annum). In the event of a default where it becomes necessary to place this account in the hands of a third party for collection, the undersigned agrees to pay all costs of collection, including reasonable attorney’s fees and court costs. I have read and understand the above statements and agree to all terms therein.