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Agreement to Pay for Physician Services

I agree to pay for the services rendered by (name of physicians or practice), as indicated

below.

Date of Service__________________ ___ Payment in full

Date to be paid___________

Date_____________ Amount to be paid___________

____ Payments will be made by cash or check

____ Payments will be made by credit card, which I authorize you to use:

Credit Card:

Visa____________________________________ Exp_______

MasterCard______________________________ Exp_______

It is understood that if the patient misses payments, without prior notification and

agreement, the practice reserves the right to transfer collections to a collection agency.

__________________________________________

Name of Patient (print or type)

__________________________________________

__________________________________________

Patient Address

__________________________________________