1258 High Street, Eugene, OR 97401
Phone 541-342-8437 | Fax 541-242-2999
Teaching Clinic Fee Agreement
Name: Date of Birth:
I agree to and understand the following statements:
- I will receive a monthly statement listing services, payments, and adjustments. The statement will specify an amount due from me, and I understand that payment is due upon receipt.
- I understand charges for minors will be billed to the legal guardian initiating services.
- I understand that CFD accepts payment by cash, check, VISA, or Mastercard.
Amount agreed per session:
By signing below, I acknowledge that I have read and agree to the above fees and responsibilities.
This document is being signed by:
If you are signing as the Personal Representative, please complete the following section; otherwise, proceed to signing the form.
Full legal name of Personal Representative:
Relationship to client:
Definition of Personal Representative:
For Adults: A person with legal authority to make healthcare decisions on behalf of the adult. Supporting documentation required.
For Youth: A parent, guardian, or other person acting in the place of a parent with legal authority to make healthcare decisions on behalf of the minor child. Supporting documentation may be required.
