Email = email@example.com
Fax = 515-255-2228
CREDIT CARD AGREEMENT
Please download, print and sign this credit card agreement to use for balances due from you after your insurance processes your claims or if you are selfpay. Please email to firstname.lastname@example.org or fax to 515-255-2228. Thank you.
Please print and complete the appropriate intake packet and return it with a copy of your insurance card and the credit card agreement to email@example.com or fax to 515-255-2228. Once the packet, card and credit card agreement are received, we will call you to schedule an appointment. Thank you.