I DECLINE autopay. I am aware that no monthly statement will be sent to me and that I have from the 1st until 27th of each month to make my monthly payment. If payment is not received by the 27th I understand that there will be a $10 charge applied to my account.
I authorize Franklin Orthodontics, PLLC to automatically charge my credit card for the charges listed
below. If payment date falls on a weekend or holiday, the payment will be processed on the
following business day. This agreement will remain in effect until cancelled by myself or Franklin
Orthodontics, PLLC, and I can cancel my autopay service at any time by calling Franklin
Orthodontics, PLLC at (717)-262-4002. For charges that cannot be completed due to insufficient
funds a $10 service charge may apply, and more than 2 failed charges may result in cancelling of my