By signing my name to this online form, I certify that I have read the information and that any questions concerning these policies have been discussed. My signature also certifies my understanding of and agreement with the policies or guidelines. A photocopy of this document is as valid as the original. You may receive a copy of this document upon request.

The policy in our office is the patient who requests treatment is responsible for all fees for services rendered. I understand that even though I have some type of insurance coverage, I am responsible for payment of services.