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James A. Penney III, DDS, PA13239 Cantrell, Suite BLittle Rock, AR 72223________________________________________________________________________Phone: (501) 227-7668Fax: (501) 227.7120Dear Patient:PAYMENT IS REQUESTED AT THE TIME OF YOUR VISITWe now offer the following payment options: Payment by cash Payment by check Payment by credit card CareCredit (card AND card holder MUST be present to process transaction)Please make your choice, sign below and return to office manager before treatment.Our office is a fully approved and accredited user of the Visa and MasterCard Health Care Program which will enable you to use your Visa and MasterCard to automatically cover amounts not paid by your insurance.If none of the options above apply, please see the office manager. Thank you.___________________________Print your name and sign belowX__________________________Date: ______________________PAGE 5 of 5 ................
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