Dental Payment Plan AgreementDental Payment Plan AgreementDental Payment Plan Agreement
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DENTAL PAYMENT PLAN AGREEMENT
I. THE PARTIES. This Dental Payment Plan Agreement (“Agreement”) dated
__________________, 20____, is by and between:
Dental Office: __________________, with a mailing address of __________________, City of
__________________, State of __________________, Zip _________ (“Creditor”), and
Debtor: __________________, with a mailing address of __________________, City of
__________________, State of __________________, Zip _________ (“Debtor”).
HEREINAFTER, the Debtor and Creditor (“Parties”) agrees to the following:
II. BALANCE. At the time of this Agreement, the Debtor owes the Creditor the amount of
__________________ Dollars ($_________) (“Current Balance”) for dental services.
III. DISCOUNTED BALANCE. In consideration of the Debtor’s faith to repay the Current
Balance in this Agreement, the Creditor agrees to: (check one)
☐ - No Discounted Balance. The Debtor shall pay the full Current Balance (“Amount Owed”).
☐ - A Discounted Balance. The Debtor shall on