Dear Dr. Pollak DMD PC,

I, , hereby agree to pay Dr. Pollak DMD PC for dental services at the time of service. I understand and acknowledge that Dr. Pollak will not bill my insurance, nor will he assist in filing any claims on my behalf. It is explicitly understood that my insurance or the patient's insurance will NOT reimburse me for any work performed by Dr. Pollak. I assume full responsibility for settling the entire fee for service directly with Dr. Pollak DMD PC at each appointment.

I further acknowledge that any outstanding balance not paid at the time of service may be subject to additional fees or collection efforts. By signing below, I affirm that I have read, understood, and agree to the terms outlined in this 100 percent fee-for-service dental contract.