thirty-twodental.com - Credit Card on File Agreement

Credit Card on File Agreement
Patient Name:*

First Name Last Name
32 Dental has implemented a new, convenient payment policy using a credit card on file, to streamline our billing and payment system to provide a seamless, convenient way for patients to pay their bills.

We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been reserved for you and when it is missed, that time cannot be used to treat another patient.

I, {name32} understand the importance of notifying the office at least 24 hours prior to my scheduled appointment that I am not able to keep my appointment. If I am experiencing an emergency, I will provide as much notice as possible to avoid being charged the Late Cancellation fee of $50. I understand that I will be charged a No-Show fee of $50 for failing to call and failing to show for my scheduled appointment

*Co-pays are still due at the time of service.

If you have any questions about our policy, please do not hesitate to ask.
By signing below, I authorize 32 Dental to keep my signature and my credit card information securely on-file in my account. I authorize 32 Dental to charge my credit card for any outstanding balances when due.

If the credit card that I give today changes, expires, or is denied for any reason, I agree to immediately give 32 Dental a new, valid credit card which I will allow them to charge over the telephone. Even though 32 Dental is not processing the new card in person, I agree that the new card may be used with the same authorization as the original card I presented.
*

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Patient’s Name *

First Name Last Name
Birth of Date*

Month Day Year
Name on Card *
Last Four Digits of Credit Card Number*

Street Address Line 2

City State / Province

Postal / Zip Code
Exp. Date*
Please fill out the information below for any other person(s) you authorize this credit card for (Click + add more)
Patient Signature*

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Patient Name*

First Name Last Name
Date*

MonthDay Year
Date
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