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Home | New Patient Center | Pediatric History Questionnaire
The undersigned agrees that all past due amounts shall be charged $10.00 per month on the unpaid balance commencing thirty (30) days after billing. The undersigned assumes and agrees to pay all collection agency fees paid by us, attorney fees, court costs, and other cost incurred while collecting the amount due.
The under signed give permission to and exchange information to those professionals that they are being referred to or to those professionals that referred them to our office. The undersigned gives permission to exchange information with their insurance company when necessary.