In the event you are not able to be present for your appointment, please list any persons authorized by the owner to approve care for the patient and a dollar amount up to which care may be authorized for.
I acknowledge legal ownership of and financial responsibility for the above listed patient. I acknowledge that as the owner of the above listed patient I am responsible any costs incurred in the course of treatment and that payment is due at the time of service. Finance charges will be applied to balances outstanding greater than 30 days.
Thank you for submitting!