Self Pay Patient Payment Agreement

I understand that I will be responsible for all charges related to the services provided to me by Trinity Whole Health Care Services LLC.

I understand that the charges presented to me are due in full on the day of service, unless arrangements have been made with the provider. I also understand that these charges are solely in relation to the professional services provided by the provider.

The patient certifies that he/she read and agreed to the forgoing, received a copy thereof, and is the patient, the patient’s representative or is duly authorized by the patient as the patient’s general agent to execute the above and accept its terms.