Date: 
Patient Name (First, Last): 
Name as it appears on Card or Bank account: 
Statement/Billing Address: 
City:    State:    Zip: 
 
1.     Credit/Debit Card #:  - - -
        Expiration Date (mm/yy):        3 Digit Security Pin#: 
 
OR 
 
2.     Account type: 
Bank Name: 
Bank Address: 
Routing Number:                                    Account Number: 
 
3.     Date of payment:                          
 
4.     I understand that my Credit / Debit Card / Bank Account will be billed on the 1st or 15th (whichever chosen) of        each month until the complete balance is paid in full to Thomas Orthodontics. If at any point of the billing process a        payment cannot be processed due to insufficient funds, there will be $25.00 reprocessing fee added to your account. Also, if        at any point your insurance is terminated or unable to pay, the remaining insurance balance will be transferred over to the        patients responsibility, and Thomas Orthodontics has the right due increase your monthly charges as appropriate. By        signing below, you give Thomas Orthodontics permission to bill directly to your Credit / Debit Card / Bank Account monthly. 
 
Signature:   Date: