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Terms and Policies Disa Dental Studio, Inc. statements are mailed at the beginning of every month. Payment is due on the 15th of the month - credit card payments are due on the 1st of the month. We are happy to accept Visa and Mastercard payments. Delinquent accounts are subject to a monthly late fee of 2% on any outstanding balance. Please authorize a credit card to be charged in case of delinquency (we will run the cards for these delinquencies on the 30th of the month and a 2% late fee will be added to the statement amount) and indicate if you choose to make your payments by credit card. FORM MUST BE COMPLETED AND FAXED TO 503-954-3356 BEFORE WE COMPLETE YOUR FIRST CASE. Thank you for your understanding and for your support!

_____________________________________________________________________________ Doctor’s name: _________________________________ License #: _____________________ Visa/Mastercard (please circle) Card #:_____________________________________________ Billing zipcode for credit card: ____________________ Exp. Date: ______________________ Authorization Signature: ________________________________________________________ Do you wish to make monthly account payments by credit card and have Disa Dental Studio, Inc. run this card on the 1st of every month? _______________ Signed __________________



Terms and policies 2014