Auto Payment Forms

To help us with your payment, please download and print the appropriate forms, fill them out and bring them to your appointment.

• Banking Office Policy -  When working with banking systems there are specific guidelines and protocal for making changes within that system.
• Checking/Savings Account ACH Withdrawl Authorization Form - To have a pre-authorized amount automatically deducted from your checking or savings account on a monthly basis.
• Credit Card Authorization Form - An authorization agreement for us to charge your credit card card (Debit cards not accepted for automatic payments.)
• ADA Dental Insurance Claim Form