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Investment Options For Your Healthy Smile
Thanks to our friend Mary Beth Bajornas at Dental Support Specialties for this great letter! Feel free to modify it any way you see fit for your practice.
“Healthy Lives Need Healthy Smiles”
Flexible & Affordable Investment Options for Your Oral Health
Patient Name: ____________________________ Date: ________________
We have many great payment options. Please check your preference(s)
___ NEW!!! Convenient & Affordable Financing (NOTE: Total Treatment has to be at least $300)
*** Dr. ____________ desires to assist his/her patients in obtaining affordable financing by paying the interest for you on select plans! You deserve a healthy mouth!
3 mos. ___________ per month for 3 months with credit approval Interest Free!
6 mos. ___________ per month for 6 months with credit approval Interest Free!
12 mos. ___________ per month for 12 months with credit approval
24+ mos. ___________ per month for 24 months with credit approval
____ 5% Pre-payment Courtesy Savings (cash, check) (must be paid PRIOR to appt)
____ 3% Pre-payment Courtesy Savings (credit card)
5% SAVINGS ______________ YOU PAY __________________
3% SAVINGS _____________ YOU PAY __________________
___ Cash/Check/Credit Card at the time of service for patient estimated portion
___ ACH monthly debit Monthly Amount $ _____________ Number of months __________
(Will need to complete funds transfer authorization)
Credit card on file: AMEX VISA MASTERCARD DISCOVER
CC# _________________________________ Exp ______ CVV________
Billing address _____________________________ Zip Code _____________________
Patient Acceptance and Signature_____________________________ Financial Coordinator ______________________________________
** All estimated patient portions are ESTIMATED only. Any portion remaining after insurance payment is the patient responsibility. Any payment remaining will be applied to the above credit card on file.
