Patient Name* First Last Date* MM slash DD slash YYYY 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*CAPTCHA
