Updated Payment Method

You are receiving this form either because there is a balance due on the account or because automatic payment is not yet set up.
Late Payment Policy for Past Due Accounts

Setting up Automatic Payments is the best way to prevent late payments. If the scheduled payment is not received within 15 days of its due date, a late fee of $25.00 will be assessed each month until the account is brought current.
Treatment Suspension

Treatment will be suspended on patients whose accounts are more than 90 days past due until the account is brought current. During treatment suspension, we will monitor oral hygiene and attend to orthodontic emergencies only; however, treatment progress will not continue and treatment length may increase. Because unsupervised orthodontic care may result in cavities, gum disease, or other serious problems, prolonged suspension and/or multiple failed appointments will result in patient dismissal.
Treatment Dismissal

If an account becomes more than 120 days past due, the patient will be dismissed from the practice and may be seen on an emergency basis only for 30 days.
Patient Name*

First NameLast Name
Would you like to set up automatic payments to prevent late payment fees?*

Yes, Bank Account (Preferred)Yes, Credit or Debit CardAutomatic Payments are already set up for my accountI decline to set up automatic payments at this time
Name on Checking Account*

First NameLast Name
Routing Number*
Account Number*
Credit Card Number*
Expiration Date*
Would you like to add a secondary method of payment to be charged in order to avoid incurring late fees if your primary method of payment has declined?*

Yes, a Bank AccountYes, a Credit or Debit CardNo, I decline to set it up at this time
Name on Checking Account*

First NameLast Name
Routing Number*
Account Number*
Credit Card Number*
Expiration Date*
AUTHORIZATION

I authorize North County Orthodontics to process debit entries to my bank or credit card account. I understand that my information will be saved on file for future transactions on my account. Furthermore I understand that my information with remain in effect until I provide reasonable notification to terminate the authorization.
Signature to Approve Automatic Payment *

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I understand the Late Payment Policy for Past Due Accounts*

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Updated Payment Method

Late Payment Policy for Past Due Accounts

Treatment Suspension

Treatment Dismissal

AUTHORIZATION

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