Please note here if you have any comments or special requests. Please write "none" if you do not have any.
I consent and agree to the services recommended to and listed by me, above. I understand there are additional charges for services as listed. While a verbal estimate should be requested and typically provided, by ticking this box and signing below I decline a written estimate unless already provided in advance for the above listed recommended tests, procedures or treatments. Payment is due at the time of services, or upon presentation of an invoice/statement. In some cases, an estimate may be presented for payment in advance. In all cases, I, the owner or agent, and that person signing this form is responsible for payment. In addition, I understand and agree that in the event of default I may be subject to additional collection and/or attorney's fees when applicable. All disputes to be resolved in Jackson County, Oregon.