Recurring Payment Form
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 firstname.lastname@example.org
or bring it with you to your next appointment.