I acknowledge that I have carefully read and understand the Office Policies and Procedures and accept all the terms as described above. I understand that Office Policies and Procedures may be amended or modified from time to time by the practice.
(Please contact our front-desk at 972-473-744 for more details regarding our rates for seeing self-pay patients.)
PATIENT EMERGENCY CONTACT
RESPONSIBLE PARTY INFORMATION (PERSON WHO IS FINANCIALLY RESPONSIBLE FOR PAYMENT)