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Dental Care & Wellness of Sonoma County


  Last name

  Mid name

  First name


Office Financial Policy

Our office financial policy is a "Zero Balance Office". This means patients are expected to pay in full at the time of the service. We require 50% of the patient's portion at the time of scheduling your appointment. This will also mean that your spot will be held on our schedule. At the time of the actual scheduled appointment you are required to pay the remainder of your balance. We want to offer our best to our patients and we are blocking this time on our schedule to care for your needs.

*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)