Payment Plan Application

Managing large payments just got easier with our Payment Plan Application, designed to help you apply for flexible payment plans that fit your budget.

To get started, simply complete the form below and select the payment plan that best suits your financial needs. Your application will be reviewed by our Billing Department, and you will receive an email once approved.

To activate the payment plan, you must register your credit card with the office manager to set up auto-pay, ensuring that payments are automatically processed on the agreed schedule. With this simple process, you can manage your payments with ease and peace of mind.

Please provide your information:

I am a …*

Client

Spouse / Partner

Parent / Guardian

Other

Relationship to Client*

Applicant Information:

Applicant Name*

First Last

Phone*

Email*

Address

Street Address ZIP / Postal Code City State / Province / Region

Client Information:

Client Name:

First Last

Date of Birth*

Phone*

Email*

Address*

Street Address ZIP / Postal Code City State / Province / Region

Treatment Location*

Cost Estimate

Co-Pay

Coinsurance

Deductible

Out of Pocket Max

Preferred Payment Plan

Payment Frequency*

Payment Amount*

Additional Comments

Consent

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