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Cardone & Associates Reproductive Medicine & Infertility, LLC

Financial Authorization Form

Financial Responsibility Form

I/we understand that without health insurance coverage, I/we are responsible for all surgical fees and full payment is due before the surgery date.

I/we give permission to charge the fee to the credit card (listed below), once I/we have been notified.

 

I/we acknowledge and accept these terms and conditions. I give Cardone Reproductive Medicine & Infertility, LLC, permission to use the above card.