Form: VSTMJ-TMJ FINANCIAL POLICY

  1. Page 1
  2. Confirm

Patient Information

FINANCIAL POLICY

WE WILL COLLECT $260.00 AT TIME OF SCHEDULING TO COVER THE INITIAL EXAM.

WE DO NOT BILL INSURANCE FOR TMJ SERVICES. PAYMENT IN FULL IS REQUIRED AT TIME SERVICES ARE RENDERED.

WE ACCEPT: CASH, CHECK, VISA, MASTERCARD, DISCOVER AND AMERICAN EXPRESS.

CANCELLATION POLICY

WE ASK FOR 24 NOTICE OF ANY CANCELLATION TO AVOID FORFEIT OF YOUR $260.00 ADVANCE PAYMENT.

THANK YOU FOR UNDERSTANDING OUR FINANCIAL POLICY. PLEASE LET US KNOW IF YOU HAVE ANY QUESTIONS OR CONCERNS.