TC Fee Agreement

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.

Leave this empty:

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Signature Certificate
Document name: TC Fee Agreement
lock iconUnique Document ID: 82351335cc11e6ab0a50ea04b1104945edb43207
Timestamp Audit
March 20, 2023 2:49 pm PDTTC Fee Agreement Uploaded by Do Not Reply - IP
March 20, 2023 2:55 pm PDTCFD Main - added by Do Not Reply - as a CC'd Recipient Ip: