I, _____________________________________________________, agree to
remit the following payments to ____________________________________:
Amount Payment Date Purchaser Initial
This payment plan is interest free and free of billing charges for the payment period; however,
I understand that in the event any of my payment is 3 days late, $10 will be added to my account.
This fee is enforced to keep costs at a reasonable level, thus preventing frequent increases in the
fees for medical services.
Method of Payment:
________ Personal Check(s):
Credit Card (Check one):
Credit Card Number: ______________________________ Expiration Date:_____________
I authorize _________________ to keep my signature on file and to charge my payments to the
credit card selected above.
Signature of Responsible Party/Cardholder
Print Name of Responsible Party/Cardholder Print Patient Name(s)
Address City State Zip
Signature of ENT & Sinus Center Representative
Print Name of ENT & Sinus Center Representative