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Financing Form

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Automatic Bank Draft Agreement

The first withdrawal will occur during the first month following placement of braces / Invisalign.

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Once the Automatic Monthly Payment Withdrawal is activated, this transaction will occur on or about the 5th day of each month for the number of months below, until my contract has been paid in full.

I understand that the option to pay in full or financing utilizing a third party company has been presented to me. The financing opportunity provided by GO Orthodontics Tampa is only a courtesy to me to facilitate the payment for orthodontic services.

I acknowledge that my financial obligation must be satisfied every month in accordance to my contract agreement and it's not related to the number of visits the patient will be seen. In other words the total fee of orthodontic services has been divided into the payments below for your convenience.

I understand that changes in the orthodontic treatment may occur. In the event that a new financial obligation would have arisen due to a change in orthodontic treatment plan, a new Automatic Monthly Payment Withdrawal contract will be made in order to satisfy my financial obligation.

I also understand that if the debit entered under this authorization is returned for insufficient funds or otherwise dishonored, I will promptly remit the total monthly payment due plus $25.00 of applicable late or returned item fees.

Should I choose to change the method of payment, I understand I will provide fifteen (15) days notice prior to the automatic drafting day.

I agreed to maintain two active methods of payments on file as it's a requirement for financing my orthodontic services.

I authorize a third party company on behalf of GO Orthodontics Tampa drafting from the second method of payment in the event the initial drafting method fails to credit my account.