Cosmetic Services. I understand and agree that I am ultimately responsible for all payments in full for all cosmetic services. I hereby certify that I have read, understand and agree to the above statements. I have been presented with written treatment plan and fee estimation, and give my full consent to the treatment in the office of Empire Dental.
Appears in 3 contracts
Sources: Office Policy Agreement / Hipaa Notice, Office Policy Agreement / Hipaa Notice, Office Policy Agreement