Financial Agreement

Review and sign our financial agreement form regarding payment policies.

Our financial agreement outlines our payment policies and your financial responsibilities as a patient. Please review this document before your appointment.

Instructions

  1. Download and review the financial agreement
  2. Print and sign the form
  3. Bring the signed form to your appointment
  4. Ask our staff if you have any questions about our payment policies
Download Financial Agreement (PDF)

Payment Policy Overview

Our financial agreement covers:

  • Payment expectations and timing
  • Insurance billing procedures
  • Co-payment and deductible responsibilities
  • Payment plan options
  • Cancellation and no-show policies

Questions?

Call us at 408-358-5123 if you have questions about payment policies or to discuss payment plan options.