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Patient Estimates


I acknowledge and understand that this is just an ESTIMATED AGREEMENT based on information provided by me (the patient) and do not include additional tests/procedures/services ordered by my physician after the initial estimate. I understand the terms and conditions of this estimate and agree to pay the full amount due prior to service. I also acknowledge that the actual price I pay may be higher or lower than this estimate and agree to pay any remaining charges incurred after billing. Additional charges must be paid at time of final billing for additional services requested by your physician.

Accept and continue