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Payment is due at the time of service. Cash and cashier checks are accepted. A fee will be charged for returned checks. If an extended payment plan is desired, please ask your credit union. MasterCard and VISA credit card payments are also welcome.
If you have any questions, please feel free to ask.
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I understand and agree that all services rendered me, my dependents, or others assigned by me to my account are
charged directly to me. I further understand I am personally responsible for payment. If I suspend or terminate
care and treatment, any fees for services rendered will be immediately due and payable.
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I understand that if I make an appointment, I am responsible for keeping that appointment. We require minimum 50% down for all scheduled treatment appointments. If payment is paid in full at appointment scheduling a 3% discount for cash/check payment will be offered. Credit card payments do not qualify for 3% discount. If full payment isn't received prior to treatment date, the 3% discount will not be available for day of treatment payment in full. In the event that I cannot make an appointment, I understand that I must provide at least 48 business hours notice and $100 will be charged per each scheduled hour. If an appointment of 2 hours or greater is necessary, I agree to pay $200 to reserve the appointment. I understand the $200 will be applied toward the cost of treatment provided during the appointment.
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We suggest and encourage you to discuss office visit and procedural costs at the time of service to avoid
misunderstandings. Failure to do so does not absolve you of responsibility for charges incurred.
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I understand that there is a charge for all dental, pain, and sleep apnea consultations with Dr. Azouz.
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I agree to be responsible for payment of all services rendered on my, or my dependent's behalf. I understand that payment is due
at the time of services unless other arrangements have been made beforehand.
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