Implant Laser Dental SPECIALTIES

MY HEALTH CARE

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Implant Laser Dental

Non-Associate

Paul Svoboda

Address: 525 East Division , 54935, Fond Du Lac, Fond Du Lac County, WI
Speciality: Implant Surgery
Phone: 9209227700
Website:

Non-Associate

Champe O.Butler

Address: 525 First Avenue, 25303, South Charleston, Kanawha County, WV
Speciality: Implant Prosthodontics
Phone: 3047444671
Website:

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This Petition Slip is for you to present to the named Healthcare Provider as a written request for a price break on the office visit/service appointment which you are responsible to schedule. If a price break has not been determined prior to your appointment, feel free to remind the Healthcare Provider/staff that you are paying out-of-pocket that day. At this time it is important for you to ask the Healthcare Provider which form of payment they accept; Cash, Check or Charge.

PAYMENT DUE

When checking in at your appointment, payment will be required prior to receiving service.

HEALTHCARE PROVIDER

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SERVICE PRICE PETITION

Office visit/service price to be determined between Patient and Healthcare Provider

PROVIDER SIGN-UP

Please ask your Healthcare Provider to visit MEDPRICE.COM to review the enrollment process. Our basic program allows Healthcare Providers to enroll as an Associate starting as low as $9.95 per month. It is designed to eliminate the 'sometimes awkward' face to face price negotiations with patients and to simplify the out-of-pocket payment method.

Print this out and take it with you to your appointment.