Read a message about COVID-19 from Dr. Siegal
This is the required payment form. You may fill out the fields below and ‘submit’ your form to the office, in which case you will be asked to sign your name on the day of your visit.

You may also click on the “Download Form” below and you can fill out the form and bring it on the day of your visit.

Dear patient,
In an effort to provide you with flexible payment arrangements, we have expanded our payment.

Payment is due at the time of treatment unless prior arrangements have been made.

We now offer the following payment options, please check relevant box.