Sayre_AutoPayment
ORTHODONTICSPAYMENT AUTHORIZATION FORMPATIENT/BILLING PARTY INFORMATIONPatient Name: Billing Party Name: Billing Street Address: Billing City: Billing State: Billing Zip: BANK DRAFT PAYMENT INFORMATIONRouting Number: Bank Account Number: Name on Account: □ Checking□ SavingsCREDIT/DEBIT CARD PAYMENT INFORMATIONCredit/Debit Card Type: □American Express □ Discover □ MasterCard □ VisaCredit/Debit Card Number: ___Expiration Date: Name on Card: PAYMENT FREQUENCY □ One-Time □ Monthly recurring on the: □ 1st □ 8th □ 15th□ Multiple Dates:_____________________________________________________________________________________ PAYMENT AUTHORIZATIONI authorize Sayre Orthodontics to process payments per my financial agreement effective today and if appropriate for the term of my contract. I understand that this authorization will remain in effect until I provide notification to terminate.Signature of Patient/Billing PartyDateJEREMY M. SAYRE DMD, PC // // 406-585-1443 // sayreortho@ ................
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