(416) 538-8883
415 Bloor Street West Suite 300
Toronto, Ontario M5S 1X6

Financial Arrangement Form

Patient Name:
Amount Owing:

Financial Agreement:

Patient has chosen to proceed with a financial plan for . The fee is $ plus lab fees (if applicable) as incurred.

A down payment for $ is required to initiate your treatment. The remaining balance of $ will be spread out over monthly payments of $ (either on the 1st or 15th of each month).

Your credit card information will be held on file to set up automated payments for your chosen day of the month (or the next business day).

Patient Name:
Patient Initials:
Bloor Dental Health Centre Toronto - Office
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