Joyful Dental Care

6314 N. Cicero Ave. Chicago, IL 60646
(773) 736-7767

Financial Agreement/Release

I, , do hereby authorize Joyful Dental Care to utilize my: (mark one)

to pay any unpaid balance remaining after my insurance company reviews my claim.

In the event my credit card is not approved, I will be personally and immediately responsible for any overdue balance as a result thereof.

Cardholder Signature: ________________________________

Witness Signature: ___________________________________
Date: _____________________
Your signature will be required.