I verbally accept the discussed treament plan, and agree to pay Spurr Family Dentistry, at the time of service is complete. If insurance is to be billed, I agree to pay my estimated portion at time of service. The office agrees to bill my dental insurance on my behalf and I understand the provisions of my dental insurance coverage and my current eligibility status. I understand that payment (if not covered by insurance) is still my responsibility.
I understand that if I fail to honor the terms of this agreement, the remaining balance will accrue interest at the highest rate allowed by law, and will become due at the request of Spurr Family Dentistry, and will be subject to any and all fees associated with the collection of this debt, including court and attorney fees.
The fees for all procedures are guaranteed for 90 days.