Dental Membership Payment Processing Setup Form
Complete this form to set up payment processing for a dental membership program.
Practice and Billing Contact
Practice / Legal Business Name
*
Practice Location or Office Name
*
Primary Billing Contact Name
*
First Name
Last Name
Email Address for Payment Notifications
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Membership Payment Setup
Membership Plan Name
*
Billing Frequency
*
Monthly
Quarterly
Annually
Custom
Membership Fee Amount
*
Payment Start Date
*
-
Month
-
Day
Year
Date
Preferred Payment Method
*
Please Select
Card on file
ACH
Invoice
Configured method
Last 4 Digits of Card
Processing Instructions and Authorization
Merchant Processor or Gateway Name
*
Settlement or Payout Instructions
Submit
Should be Empty: