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Boggy Creek - NEW CLIENT AND PATIENT INFORMATION

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    I UNDERSTAND THAT FEES ARE TO BE PAID AT THE TIME SERVICES ARE RENDERED. WE WILL GLADLY PREPARE A WRITTEN ESTIMATE IF YOU DESIRE. PLEASE ASK THE DOCTOR SHOULD IT BECOME NECESSARY TO COLLECT THIS AND ANY FUTURE AMOUNTS THROUGH AN ATTORNEY, THE UNDERSIGNED AGREES TO PAY ALL COSTS OF COLLECTION AND EXPENSES, INCLUDING A REASONABLE ATTORNEY'S FEE. IF THIS ACCOUNT IS ASSIGNED TO A COLLECTION AGENCY, AN ADDITIONAL FEE OF 33% OF THE AMOUNT OWED WILL BE ADDED.

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    If you have been referred by another doctor, please fill in the information below.
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