New Client Form

Financial Agreement: I understand that PAYMENT IS DUE AT THE TIME OF SERVICE. I recognize that this facility does not offer payment plan options. I hereby agree to the following terms and conditions. Checks, which are declared with non-sufficient funds, will be charged a $35.00 service fee. Also, I agree to pay a collection fee of 33% of the total owed if my bill is sent to collection, plus all attorney fees, and court costs incurred by the creditor.