Financial Agreement
			Date:
	I fully understand and agree to the financial agreement and treatment that has been recommended. If no services are performed under this agreement, a refund will be issued at a customer's written request minus twenty percent administrative fee. Otherwise, all fees are non-refundable. I agree that the insurance amount is an estimate only and that I am personally responsible for any balance not paid by my insurance. The full case fee above does not cover any other treatment rendered and/or required by other dentists, dental specialists, or other healthcare providers. When you provide a check as payment, you authorize us either to use the information from your check to make a one- time electronic fund transfer from your account, or to process the payment as a check transaction. For inquiries, please call our office. When we use information from your check to make an electronic fund transfer, funds may be withdrawn from your account as soon as the same day you make your payment, and you will not receive your check back from your financial institution. All returned checks are subject to a $30.00 fee for Non-Sufficient Funds.