Recurring Payment Form

recurring payments.pdf

Please click the link above 


Thank you for the opportunity to help you meet your oral health goals.


Recurring Payments Will Make Your Life Easier:

·         It is convenient (saving you time and postage)

·         Your payment is always on time (even if you’re out of town), eliminating late charges.


Here’s How Recurring Payments Work:

You authorize charges as needed to your Visa, MasterCard, American Express, or Discover card. You will be charged as necessary for the total amount due if the bill is $60 or less. A receipt will be e-mailed to an e-mail you provide to us and the charge will appear on your credit card statement. You agree that no prior-notification will be provided if the total payment is $60 and or less. If your bill is more than that amount you will receive notice from us. 


If you are interested in this option, please fill out this form

and e-mail it to us at

or bring it with you to your next appointment. 


8870 Zionsville Road, Suite 100
Indianapolis, IN 46268
(317) 298-3384

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