Electronic Debit - 0% No Fee

Direct Bill Payment via ACH to Eagle Dental LLC

First name

Last name

Address

Phone

Payment amount

Type of payment?

One-time

Monthly

Monthly recurring payments process on the 15th day of the month. (If 15th falls on non-business day, payments process next day).

Account Type?

Checking

Savings

Financial institution

Example: name of bank or credit union

9-Digit Routing Number

Account Number

Please verify correct number to avoid a bank penalty.

Direct Payment via ACH is the transfer of funds from a consumer account for the purpose of making a payment.

I (we) hereby authorize Eagle Dental LLC to initiate debit entries, or if necessry credit adjustment or any debit error, to my (our) account at the depository financial institution named above. I (we) acknolwedge that the origination of ACH transactions to my *our ) account must comply with the provisions of U.S. law. This authroization is to remain in full force and effect until Eagle Dental LLC has received written notification from the patient of its termination in such time and in such manners as to afford Eagle Dental LLC a reasonable opporutnity to act on it.

Authorized Signature

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0% No Fee Please check your statement and remove fee from total.

3% Processing Fee Please check your statement and include fee in total.

0% No Fee

Electronic Debit - 0% No Fee

0% No Fee
Please check your statement and remove fee from total.

3% Processing Fee
Please check your statement and include fee in total.