681 Encinitas Blvd Suite #309
Encinitas, CA 92024
760-632-0320
Patient name:
Treatment:
Total cost of treatment:
$
Enter MBD plan discount:
$
Percent discount if paid in full:
%
Patient Total:
$0
By prepaying your treatment, you are saving $0.
Notes:
Payment: Pre payment is due at time of scheduling in order to reserve your appointment and any changes to the appointment date must be made at least 7 days in advance.
Insurance: This treatment plan is not a guarantee of insurance payment. We will file your insurance claim and your insurance company will send any available benefits directly to you.
This treatment plan is valid for 30 days.
Your signature below indicates that you have been informed about your treatment and estimated associated costs.
Patient signature
Date
Treatment coordinator: