Cash Patient Policy Agreement

GENERAL FEE SCHEDULE:

PAYMENT DUE:

NOTE: Your payment includes the face-to-face consultation or follow-up visit time spent with our Physician, which can include radiographs/x-rays (when/if applicable).

NOTE: In-Office services and procedures can include (but are not limited to): bandage applications/changes, splints, casts, injections, suture application and/or removal, and/or other minor procedures that can be performed in our Office without the necessity for formal surgery at another (surgical) facility.

*Payment for these services may be required prior to being rendered (or after being rendered) at our discretion.

NOTE: Surgical fees quoted and paid in our Office are for our Physician/Surgeon fees only. Our fee does not include fees for the surgery facility, or anesthesia or any other third-party fees. Our Office will instruct you on whom to contact (for payment arrangements for other surgery-related services) when your surgery has been discussed and pre-scheduled.

NOTE: Your payment includes the face-to-face consultation or follow-up visit time spent with our Therapist and staff. Your payment does not include all other therapy services and/or products.

NOTE: Therapy services can include (but is not limited to): bandage applications/changes, splints, therapy exercise/modality education and/or one-on-one rehabilitation services by our Therapists and staff.

*Payment for these services may be required prior to being rendered (or after being rendered) at our discretion.