Credit Card Authorization
Credit card on file authorization for treatment charges and copays.
- 7 days free
- Cancel any time
- 10 languages
- No patient data stored on our servers
- Fields
- 11
- Practice type
- Dental
- Category
- Financial & Billing
- Languages
- English
- Editable
- Yes — add, remove and reword fields
- Sharing
- Print, PDF or a secure link
Credit Card Authorization — preview
Sample layout generated from the actual template.
Insurance Information
Free to start — your edits are saved as you go.
About this form
The credit card authorization is a financial & billing document used by dental practices. Credit card on file authorization for treatment charges and copays. 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 11 fields:
- Patient Name — Text
- Cardholder Name — Text
- Card Type (Visa, MC, Amex) — Text
- Last 4 Digits of Card — Text
- I authorize charges for dental services rendered — Multiple choice
- I authorize charges for copays and deductibles — Multiple choice
- Do you have dental insurance? — Single choice
- Insurance Provider — Text
- Cardholder 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.