Recurring Payment Authorization

About this form

The recurring payment authorization is a financial & billing document used by dental practices. Authorization for scheduled recurring payments with terms and cancellation policy. 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 Amount — Text
• Payment Frequency — Single choice
• Start Date — Date
• End Date — Date
• I authorize recurring charges as described — Multiple choice
• 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.