PROFESSIONAL FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED. PLEASE CHECK YOUR PREFERRED METHOD OF PAYMENT BELOW.

We will gladly prepare a written estimate if you desire. Please ask the receptionist or doctor.

I AM RESPONSIBLE AND AGREE TO PAY IN FULL THE TOTAL CHARGES FOR SERVICES RENDERED AT THE TIME OF DISCHARGE AND ANY FEES INCURRED FOR COLLECTION OF SAID CHARGES. I UNDERSTAND THAT THE FEES ARE BASED ON TREATMENT DEEMED NECESSARY AT THE TIME OF EXAM, TREATMENT OR ADMISSION AND THAT THE ESTIMATE FEE MAY BE RAISED OR LOWERED BY THE ADMINISTRATION OF TREATMENT, MEDICATION, SURGERY OR DIAGNOSTIC TEST.