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I hereby understand and agree that if any amount remains unpaid on my account. I authorize Sheppard Centre Dental to debit my credit card for the unpaid balance.

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I authorize release to my insurance company and/or plan administrator, the information contained in claims submitted electronically.

Yonge Sheppard Centre Mall, 4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

4841 Yonge St, North York, ON

(647) 953-4630

info@sheppardcentre.dental

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