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PAY M EN T A ERA N GEM EN T FORM NAME OF PATIENT: (patient) Payment Agreement: I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice

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printfriendly is a tool that helps users to easily format and print web pages. PDF stands for Portable Document Format, which is a file format used to present and exchange documents reliably, independent of software, hardware, or operating system.

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