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Please provide the information below as completely as possible. All information is strictly confidential.
This Policy helps control costs on which we base our fees.
I am financially responsible for the patient described about and agree to pay all fees incurred. I understand that any medical or surgical procedure is attended by some risk and that it is not possible to guarantee the successful outcome of any such procedure. This agreement is in force indefinitely from this date unless I notify the clinic in writing to the contrary.