Welcome to ClinCheckHelp.Net - Dr. Perry Jones

Print for Check Payments

Fees Schedule and Mailing Information for Doctors who want to pay by CHECK only. Please PRINT THIS PAGE, fill out top portion and check the boxes below, add up your total, and mail check along with this form to the consultant's address below.

Dr. Jones will respond as soon as we receive your check. Thank you.

Please fill out the information below. Dr. Jones will take a look at your case file. All fields are required!

Dr's. Email Address:

Dr's. Name:

Address:

Phone:

Patient's Name:

Dr's. Username

Dr's. Password

Yes: I have read and I understand the Client Service Agreement CONSENT FORM.
 
PRE-SUBMISSION ADVICE (PSA) $50.00
COMPREHENSIVE SERVICE
(RX FORM)
$250.00
COMPREHENSIVE SERVICE
(CLINCHECK MODIFICATIONS ONLY)
$200.00
COMPREHENSIVE SERVICE
(CLINCHECK MID COURSE CORRECTION/REFINEMENT)
$200.00
PHONE CONSULT
15 MINUTES EACH
$100.00ea

 

Total Amount of Check: $__________________________________

 

ALL FEES ARE NON-REFUNDABLE.

MAIL CHECK TO:

Perry Jones, DDS
c/o ClinCheckHelp.Net
2803 McRae Road, Suite B2
Richmond, VA 23235



 

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