Credit Card Installments | Dental Health by Herre Online Payment

Monthly Payment Details

*This information is required

Patient Name*

First Last

Account Number

NOTE: Please calculate what your monthly payment amount should be and enter the first Installment amount below. The first installment payment will be made today once you submit this form. Your remaining payments will auto charge on the same day each month for the number of months you select in the dropdown menu. For example, if today is the 1st of the month, your first payment will go through today, and all following monthly payments will be charged on the 1st of each month.

Your remaining payments will auto charge on the same day each month until the balance is paid off.

To cancel the recurring payment, you will be required to call our business office at 913-491-4466 or email [email protected].

How Many Times Your Payment Should Recur?*

Monthly Payment Amount*

Comments

Billing Details

*This information is required

Contact Name*

First Last

Email*

Phone*

Billing Address*

Street Address Address Line 2 City State ZIP Code

A 10 business day advance notice is required to process the cancellation request. By submitting this form, you acknowledge that the first installment payment will be made today and agree to monthly installment payments.*

I understand & acknowledge this

Secure Credit Card

Card Holder*

Card Number*

Card Expiration*

Card CVV*

Total

$0.00

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Monthly Credit Card Installments

Monthly Payment Details

Billing Details