Link to Online Form: Pay with Credit Card

Pay with Credit Card

Please complete, read, and accept for access to the secure online payment form.
If you access our website or forms from a work computer, please be aware that your employer’s security settings may block access. If that happens, we recommend using a personal device or connecting through a home network instead.
Patient Name*

patient first namepatient last name
Second Patient Name (optional)

patient first namepatient last name
Third Patient Name (optional)

patient first namepatient last name
Fourth Patient Name (optional)

patient first namepatient last name
Your Name*

your first nameyour last name
DrTOrthdontics.com links to TWO secure online forms: PAY WITH CREDIT CARD and UPDATE CREDIT CARD ON FILE. Each form serves a unique function.

Please review both online form types, detailed below, to ensure your selection of PAY WITH CREDIT CARD is the correct form for your needs. In some instances, you will need to complete BOTH online forms.

PAY WITH CREDIT CARD...
- DOES process a one-time payment.
- DOES process the one-time payment required when your credit card is declined/expired, and you received notice to pay your monthly fee.
- DOES NOT change the credit card information stored for recurring payments of your monthly fee.
UPDATE CREDIT CARD ON FILE...
- DOES change the credit card information for recurring payments, including changing the authorized card or authorizing an expiring card with its new expiration date and CVV. (Deadlines apply: For your changes to take effect for the upcoming monthly fee, the UPDATE CREDIT CARD ON FILE form must be received before the Practice closes on our last business day of the month.)
- DOES NOT process a one-time payment.
- DOES NOT process the one-time payment required when your credit card is declined/expired, and you received notice to pay your monthly fee.
The payment plan terms are detailed in the Contract for Orthodontic Treatment and the Authorization for Recurring Credit Card Payments.

One-time payments and changes to credit card information are available ONLINE ONLY.

Please utilize the appropriate, secure online form for your needs. In some instances, you will need to complete BOTH online forms.
I understand and I wish to proceed to the PAY WITH CREDIT CARD online form and make a one-time payment.No, I do not understand and I need help.I clicked the PAY WITH CREDIT CARD link by mistake.
Should be Empty: