Auto-Pay Authorization in Medford & Ashland, OR | Schmidl Orthodontics

Patient Name*
First Last
Date*
Bank ACH routing #*
Bank Account #*
Please choose type:*
- Personal
- Business
Checking/Savings?*
- Checking
- Savings
Date of the month to withdraw funds*
- 5th
- 12th
- 19th
- 26th
I authorize Schmidl Orthodontics to make monthly withdrawals from my account in the agreed to amount on my financial contract.
Responsible Party*
Responsible Party Signature*

Medford Office

Address 2937 Siskiyou Blvd # 2
Medford, OR 97504

Contact (541) 773-6600

Ashland Office

Address 1532 Siskiyou Blvd,
Ashland, OR 97520

Contact (541) 482-4343