Rotramel Family Dentistry

"Blessed are they who engage in lively conversation with the helplessly mute for they shall be called DENTIST"

Services/Restorative Dentistry

**This form is only for reference purposes. An actual signature on a form will be required at the time of your appointment.

 

Dr. George A. Rotramel, DMD
113 E. Pembroke Street
Tuscola, IL 61953
217-253-5222

 

Professional Services Agreement

Patients account balances are due at the time of services. In the event all or any portion of an account is more than thirty (30) days past due, interest shall accrue at the rate of 1 1/2 % per month on the unpaid balance which is more than thirty days past due or $1.00 per month, whichever is greater.

There will be a $25.00 charge for a check returned for any reason.

In the event your account is past due, it may be turned over to a collection agency. If you account is not paid in full and this account is turned over to a collection agency and/or attorney, then you agree to be responsible for all reasonable fees necessary for the collection of the delinquent account including, but not limited to, collection agency fees of 50% of the balance due and costs and reasonable attorney's fee of 33% of the balance.

In consideration for services rendered and to be rendered, the undersigned patient agrees to the foregoing terms and conditions and acknowledges receipt of a copy of this agreement.

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