Financial Consent Form

$ 99.00

Tax included.

Description

No surprises at the front desk. This form ensures patients understand their out-of-pocket costs, Medicare gaps, and payment expectations before treatment starts. Reduces billing disputes and protects your revenue.

Key Features

Itemised treatment and fee schedule
Out-of-pocket and Medicare gap disclosure
Payment terms and methods
Prepaid package and refund provisions
Patient acknowledgement of costs
Customisable fee schedule, example done for you

For Who

Any clinic charging out-of-pocket fees, running prepaid packages, or operating gap-payment models.

For What

Use before any chargeable service, before the first appointment of a treatment plan, and any time fees change.

Disclaimer

Point-in-time document at date of purchase. Customise for your jurisdiction, services, and clinical context before use. Not legal advice. Membership tier includes ongoing updates as regulations change.