Payment Agreement Form

This Treatment Coordinator resource document provides a form to confirm an agreement between the practice and the patient to receive payment for treatment and services. One agreement is good for each patient and is valid until the patient requests and updates the financial agreement.

Treatment Payment Agreement Form

One agreement is good for each patient and is valid until you request and update the financial agreement. Payment arrangements are required at the time of scheduling your appointment.

Date _____________ Patient Name _________________________________

Total TXP $____________ Estimated of Out of Pocket $_______________

We offer the following payment options (please choose one):

______ PAYMENT AT THE TIME OF SERVICE (We accept Cash, Check, MasterCard, Visa, Discover and American Express)

** entire out of pocket estimate for services rendered is due the day of treatment.

View the complete document and print out a copy for your office below!
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