503-123-1234
Office: 503-554-0036 | After-hours: 503-294-1732
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Self-Pay Agreement

You have notified our office staff that you are currently without health care coverage or are choosing not to have coverage. We would like to take this opportunity to let you know the options that are available to you and your family.

Vaccines for Children

We participate in the Vaccines for Children (VFC) program. We can provide vaccines to your child for a minimal cost for the administration of the vaccine.

Courtesy Discount

We offer a 20% courtesy discount if you pay on the day of service. This does not include vaccines.

Payment Agreement Terms

Balances over $300 will require a payment agreement.

Additional Fees

Your child’s visit may include services that incur additional fees. These services can include and are not limited to: developmental assessments, questionnaires, medication, supplies, etc These charges may not be known prior to the exam.

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Self-Pay Agreement

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Complete List of Clinic Forms

Please call the clinic at 503-554-0036 with any questions regarding these forms.

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