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Patient Forms - Financial Policy  

Click on the link below to view the Financial Policy.

Financial Policy Form (pdf)

After reading the Financial Policy, you may digitally sign the form by entering your name and date below. Otherwise, you may sign the form when you arrive for your appointment.

By typing your name in the space provided below, this serves as your digital signature which affirms you have read and understand the financial policy and agree to its terms. If you have insurance, you also direct your insurance carrier to issue payment directly to Lenz Family Dental.

Signature of Patient (Please type your full name): Signature is Required.

     Date: 


 
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