Patient Refund Release Form

Legal Eviction Notice

Release Of Liability

Release and waiver (refund of treatment fee) in consideration of the patient refund release form waiver of all costs of treatment incurred to date and/or the return of all fees paid for the orthodontic treatment of (myself) (my child) and/or the payment of $_____,. Cna sample form: refund/fee waiver release. in exchange for the payment or fee waiver i acknowledge receiving at this time, in the amount of __(insert

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