FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT
I, __________________________authorize treatment for the person named above and agree to pay all fees and charges for such treatment until the patient turns _________ years of age.
I agree to pay all charges promptly unless credit arrangements are agreed upon in advance. Charges shown by statements are agreed to be correct and reasonable unless protested in writing within thirty days of billing date.
NOTICE: Do not sign this agreement before you agree to the conditions set forth. You are entitled to a copy of his agreement.