Complete this form, print it out, and send a copy with each payment you mail in for your pre-payment account. No Personal Checks Accepted. Please mail in only Money Orders or Cashier's Checks made payable to: Charles W. Monteith MD PA
Amount of Payment: $
Activation of the pre-payment account requires an initial $500 non-refundable administration fee payable by cashier’s check or money order. The non-refundable administration fee will be applied towards the total cost of surgery.
Signature: __________________________________ Date: __________________________________