Payment Agreement Form

Payment Agreement Form

Step 1 of 2

MM slash DD slash YYYY
Patient Name(Required)
We accept most private insurances and Medicaid. We do not accept Medicare.
 Method of Payment: Cash, Check, and all major credit cards.
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Longview Location
Monday - Thursday8:00 AM — 5:00 PM
Friday8:00 AM — 3:00 PM
Saturday - SundayClosed
Kilgore Location
Monday - Thursday8:00 AM — 5:00 PM
Friday8:00 AM — 3:00 PM
Saturday - SundayClosed