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Orthodontic Billing Authorization Form

Asks about responsible party name, treatment type, and total treatment cost. Built for orthodontic specialty practices.

Questions
10
Page
1
Time
about 3 min

Includes

  • E-signature
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Your practice

Orthodontic Billing Authorization Form

Live preview. Tap through it like a patient.

Who it is for

  • Orthodontic specialty practices
  • General dentistry offices offering orthodontics
  • Pediatric dental practices with orthodontic services
  • Clear aligner provider offices
  • Multi-location orthodontic groups

Formisoft for DentalFormisoft for Pediatrics

What's inside

Before you publish: Review amounts, payment terms, and authorization wording for your practice before sharing.

  1. Responsible Party NameText
  2. Patient NameText · Required
  3. Treatment TypeLong Text
  4. Total Treatment CostNumber
  5. Insurance Coverage AvailableLong Text
  6. Insurance CarrierText
  7. Orthodontic Lifetime MaximumNumber
  8. Down Payment AmountNumber
  9. Monthly Payment AmountNumber
  10. Payment Authorization SignatureE-Signature

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Orthodontic Billing Authorization Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

Yes. You can add, remove, reorder, or reword any of the 10 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Orthodontic Billing Authorization Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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