Ana Paula Gomes, DMD Alan W. James, DMD Rupal S. Patel, DM

 Ana Paula Gomes, DMD Alan W. James, DMD Rupal S. Patel, DMD In an effort to provide you with flexible payment options, we have expanded our payment policy and are happy to work with you. We offer the following payment options for patients with no insurance coverage and for balances remaining after insurance has covered their contractual obligations. You will be given an estimated patient responsible amount at your visit. It can be handled in one of the following ways: ⃝ Cash ⃝ Check ⃝ Credit Card (Visa, MasterCard, American Express, Discover) ⃝ Care Credit Please check all that are applicable. Thank you. Printed Name _____________________________________________ Signature _________________________________________________ Date ________________