Auto-Pay Authorization Form
Automatic payment enrollment for recurring balances or memberships.
- 7 days free
- Cancel any time
- 10 languages
- No patient data stored on our servers
- Fields
- 8
- Practice type
- Dental
- Category
- Financial & Billing
- Languages
- English
- Editable
- Yes — add, remove and reword fields
- Sharing
- Print, PDF or a secure link
Auto-Pay Authorization Form — preview
Sample layout generated from the actual template.
Free to start — your edits are saved as you go.
About this form
The auto-pay authorization form is a financial & billing document used by dental practices. Automatic payment enrollment for recurring balances or memberships. In BoomCloud Forms it is a starting point: every field, heading and statement can be edited before you share it with patients.
Practices may use this template as a starting point and should review the wording against their own professional, regulatory and legal requirements before use.
What's included
This template ships with 8 fields:
- Patient Name — Text
- Payment Method on File — Text
- I authorize automatic payments for my account balance — Multiple choice
- I understand I will receive notification before each charge — Multiple choice
- I can cancel auto-pay with 30 days written notice — Multiple choice
- Maximum Charge Amount Per Transaction — Text
- Patient Signature — Signature
- Date — Date
When practices use it
Dental teams typically attach this form to the check-in or treatment-planning workflow, when payment responsibility is agreed. It can be sent digitally ahead of the visit, completed on a tablet in the office, or printed as a PDF.
How to customize it
- Reword any question, add fields, or remove ones your practice doesn't need.
- Apply your practice name, logo and colors so the form matches your brand.
- Switch to another supported language where a translated version exists.
- Share a secure link with the patient, or download a print-ready PDF.